x output: html_document: <<<<<<< HEAD highlight: tango theme: readable ======= fig_width: 9 fig_height: 7 >>>>>>> ffdce05e27cdec45aa069f55b77b5c4609b13675 — ## YAML — author: “Chinny90” <<<<<<< HEAD title: “Applied_Health_Practicals0” ======= title: “Applied_Health_Practicals” >>>>>>> ffdce05e27cdec45aa069f55b77b5c4609b13675 output: html_document date: “2024-06-04” — — author:“ChinnyB00928009” title: “Practical1” output: html_document date: “2024-06-04”
knitr::opts_chunk$set(echo = TRUE)
library(readr)
library(dplyr)##
## Attaching package: 'dplyr'## The following objects are masked from 'package:stats':
##
## filter, lag## The following objects are masked from 'package:base':
##
## intersect, setdiff, setequal, unionlibrary(tidyr)
library(ggplot2)
library(scales)##
## Attaching package: 'scales'## The following object is masked from 'package:readr':
##
## col_factorlibrary(tidytext)
library(textstem)## Loading required package: koRpus.lang.en## Loading required package: koRpus## Loading required package: sylly## For information on available language packages for 'koRpus', run
##
## available.koRpus.lang()
##
## and see ?install.koRpus.lang()##
## Attaching package: 'koRpus'## The following object is masked from 'package:readr':
##
## tokenizelibrary(clinspacy)## Welcome to clinspacy.## By default, this package will install and use miniconda and create a "clinspacy" conda environment.## If you want to override this behavior, use clinspacy_init(miniconda = FALSE) and specify an alternative environment using reticulate::use_python() or reticulate::use_conda().library(topicmodels)
library('reshape2')##
## Attaching package: 'reshape2'## The following object is masked from 'package:tidyr':
##
## smithslibrary(stringr)This practical is based on exploratory data analysis, named entity recognition, and topic modelling of unstructured medical note free-text data derived from electronic medical records (EMR). Real EMR data is very difficult to access without a specific need/request so this data set is derived from medical transcription data instead. I’ll also caveat that the options of natural language processing (NLP) in R are far inferior to those available in Python.
First, install the packages in the setup block
(install.packages(c("readr", "dplyr", "tidyr", "ggplot2", "tidtext", "textstem", "clinspacy", "topicmodels", "reshape2"))).
Note: To try and make it clearer which library certain functions are coming from clearer, I’ll try to do explicit imports throughout this notebook.
Data Parsing
After that we can grab the dataset directly from the
clinspacy library.
raw.data <- clinspacy::dataset_mtsamples()
dplyr::glimpse(raw.data)## Rows: 4,999
## Columns: 6
## $ note_id <int> 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 1…
## $ description <chr> "A 23-year-old white female presents with complaint …
## $ medical_specialty <chr> "Allergy / Immunology", "Bariatrics", "Bariatrics", …
## $ sample_name <chr> "Allergic Rhinitis", "Laparoscopic Gastric Bypass Co…
## $ transcription <chr> "SUBJECTIVE:, This 23-year-old white female present…
## $ keywords <chr> "allergy / immunology, allergic rhinitis, allergies,…There is no explanation or data dictionary with this dataset, which is a surprisingly common and frustrating turn of events!
1 Using the output of dplyr’s glimpse
command (or rstudio’s data viewer by clicking on raw.data
in the Environment pane) provide a description of what you think each
variable in this dataset contains.
note_id:integer variable that serves as a unique identifier for each note entry. For example; 1
description: this character variable holds a brief description of the patients’ presentation and reason for visit. For example; A 23-year-old white female presents with complaint of allergies.
medical_specialty: this caharacter variable contains information that specifies medical field relevant to the note.For example;Allergy / Immunology
sample_name:holds the specific medical procedure as detailed in the note. For example; Allergic Rhinitis
transcription: This is an unstructured detailed note about the patient, diagnosis, results of examination and treatment plan. SUBJECTIVE:, This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals: Weight was 130 pounds and blood pressure 124/78.,HEENT: Her throat was mildly erythematous without exudate. Nasal mucosa was erythematous and swollen. Only clear drainage was seen. TMs were clear.,Neck: Supple without adenopathy.,Lungs: Clear.,ASSESSMENT:, Allergic rhinitis.,PLAN:,1. She will try Zyrtec instead of Allegra again. Another option will be to use loratadine. She does not think she has prescription coverage so that might be cheaper.,2. Samples of Nasonex two sprays in each nostril given for three weeks. A prescription was written as well.
keywords: This holds keywords or tokens from the note. allergy / immunology, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic,
Let’s see how many different medical specialties are featured in these notes:
raw.data %>% dplyr::select(medical_specialty) %>% dplyr::n_distinct()## [1] 40There are 40 different medical specialties featured in the notes within the dataset.
So, how many transcripts are there from each specialty:
ggplot2::ggplot(raw.data, ggplot2::aes(y=medical_specialty)) + ggplot2::geom_bar() + labs(x="Document Count", y="Medical Speciality")
Each bar represents a medical specialty, and the height of the bar indicates the number of transcripts associated with that specialty.
Let’s make our life easier and filter down to 3 specialties: a diagonstic/lab, a medical, and a surgical specialty
filtered.data <- raw.data %>% dplyr::filter(medical_specialty %in% c("Orthopedic", "Radiology", "Surgery"))
print(filtered.data)## note_id
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## description
## 1 Austin & Youngswick bunionectomy with Biopro implant. Screw fixation, left foot.
## 2 This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane. The patient is being brought in for YAG capsular discission.
## 3 Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.
## 4 Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue, secondary closure of wound, and VAC insertion.
## 5 Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.
## 6 A complex closure and debridement of wound. The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.
## 7 Excision of dorsal wrist ganglion. Made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.
## 8 Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.
## 9 Vitrectomy under local anesthesia.
## 10 Vitrectomy under general anesthesia
## 11 Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.
## 12 Pars plana vitrectomy, membrane peel, 23-gauge, right eye.
## 13 Unilateral transpedicular T11 vertebroplasty.
## 14 Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias
## 15 Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.
## 16 Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.
## 17 Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.
## 18 Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.
## 19 Fertile male with completed family. Elective male sterilization via bilateral vasectomy.
## 20 Desire for sterility. Vasectomy. The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.
## 21 Endoscopic third ventriculostomy.
## 22 Burr hole and insertion of external ventricular drain catheter.
## 23 Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.
## 24 Normal vasectomy
## 25 Normal vasectomy
## 26 Voluntary sterility. Bilateral vasectomy. The vas deferens was grasped with a vas clamp. Next, the vas deferens was skeletonized. It was clipped proximally and distally twice.
## 27 Laparoscopic-assisted vaginal hysterectomy. Abnormal uterine bleeding. Uterine fibroids.
## 28 Vaginal Hysterectomy. A weighted speculum was placed in the posterior vaginal vault. The cervix was grasped with a Massachusetts clamp on both its anterior and posterior lips.
## 29 Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes.
## 30 Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.
## 31 Upper endoscopy with removal of food impaction.
## 32 Exam under anesthesia with uterine suction curettage. A 10-1/2 week pregnancy, spontaneous, incomplete abortion.
## 33 Urgent cardiac catheterization with coronary angiogram.
## 34 Uvulopalatopharyngoplasty and tonsillectomy. The patient with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.
## 35 Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.
## 36 A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.
## 37 Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve.
## 38 Upper endoscopy with foreign body removal (Penny in proximal esophagus).
## 39 Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.
## 40 Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.
## 41 Transurethral resection of the bladder tumor (TURBT), large.
## 42 Decompression of the ulnar nerve, left elbow. Left cubital tunnel syndrome and ulnar nerve entrapment.
## 43 Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia.
## 44 Tube Shunt - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template.
## 45 Laparoscopic tubal sterilization, tubal coagulation.
## 46 Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa. Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.
## 47 Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.
## 48 Desires permanent sterilization. Laparoscopic tubal ligation, Falope ring method. Normal appearing uterus and adnexa bilaterally.
## 49 Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.
## 50 True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.
## 51 Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.
## 52 Postpartum tubal ligation and removal of upper abdominal skin wall mass.
## 53 Laparoscopic tubal fulguration.
## 54 Laparoscopic bilateral tubal ligation with Falope rings.
## 55 Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique. This lady has a bowel obstruction. She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.
## 56 Trigger thumb release. Right trigger thumb. The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release).
## 57 Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy.
## 58 Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.
## 59 Need for intravenous access. Insertion of a right femoral triple lumen catheter. he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.
## 60 Trigger finger release. A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.
## 61 Trigger thumb release. A transverse incision was made over the MPJ crease of the thumb. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.
## 62 Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.
## 63 Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.
## 64 Tracheotomy for patient with respiratory failure.
## 65 Trabeculectomy with mitomycin C - Sample/Template.
## 66 Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.
## 67 Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. Ventilator-dependent respiratory failure and laryngeal edema.
## 68 Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.
## 69 Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.
## 70 Left thyroid mass. Left total thyroid lumpectomy. The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.
## 71 Total knee replacement. A midline incision was made, centered over the patella. Dissection was sharply carried down through the subcutaneous tissues. A median parapatellar arthrotomy was performed.
## 72 Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye. Uncontrolled open angle glaucoma and conjunctival scarring, left eye.
## 73 Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease.
## 74 Right total knee arthroplasty - Osteoarthritis, right knee.
## 75 Total left knee replacement. Degenerative arthritis of the left knee. Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.
## 76 NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.
## 77 Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella. All components were cemented with Cobalt G.
## 78 Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty.
## 79 Right knee total arthroplasty. Degenerative osteoarthritis, right knee.
## 80 Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.
## 81 Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues.
## 82 Right hip osteoarthritis. Total hip replacement on the right side.
## 83 Total abdominal hysterectomy (TAH) with a uterosacral vault suspension. Enlarged fibroid uterus and abnormal uterine bleeding.
## 84 Aortic stenosis. Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.
## 85 Total abdominal hysterectomy.. Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.
## 86 Total Abdominal Hysterectomy (TAH). An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum. Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges.
## 87 Total abdominal hysterectomy. Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis. On laparotomy, the uterus did have multiple pedunculated fibroids.
## 88 Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.
## 89 Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.
## 90 Tonsillectomy and adenoidectomy. Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.
## 91 Tonsillectomy and adenoidectomy. McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.
## 92 Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum
## 93 Tonsillectomy. Chronic tonsillitis.
## 94 Tonsillectomy. Tonsillitis. McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.
## 95 Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.
## 96 Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.
## 97 Total thyroidectomy. The patient is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.
## 98 Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.
## 99 Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.
## 100 Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.
## 101 Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.
## 102 History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle. Insertion of tissue expander to the medial and lateral wound.
## 103 Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.
## 104 Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.
## 105 Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.
## 106 A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.
## 107 Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left.
## 108 Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.
## 109 Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft.
## 110 Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.
## 111 Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.
## 112 Bilateral temporal artery biopsy. Rule out temporal arteritis.
## 113 Thoracentesis, left. Malignant pleural effusion, left, with dyspnea.
## 114 Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.
## 115 Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.
## 116 Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.
## 117 Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.
## 118 Thoracentesis. Left pleural effusion. Left hemothorax.
## 119 Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.
## 120 Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.
## 121 Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.
## 122 Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.
## 123 Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.\r\n
## 124 Full-mouth extraction of teeth and alveoloplasty in all four quadrants.
## 125 Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.
## 126 Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.
## 127 Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.
## 128 Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.
## 129 Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot.
## 130 Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy. Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.
## 131 Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.
## 132 Total abdominal hysterectomy and bilateral salpingo-oophorectomy.
## 133 Missed abortion. Suction, dilation, and curettage.
## 134 Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.
## 135 Closure of gastrostomy placed due to feeding difficulties.
## 136 Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery.
## 137 Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.
## 138 Subxiphoid pericardiotomy. Symptomatic pericardial effusion. The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.
## 139 Superior labrum anterior and posterior lesion repair.
## 140 Suction dilation and curettage for incomplete abortion. On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.
## 141 Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome.
## 142 Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.
## 143 Emergent subxiphoid pericardial window, transesophageal echocardiogram.
## 144 Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.
## 145 Insertion of right subclavian central venous catheter. Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.
## 146 Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy
## 147 Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending.
## 148 Spontaneous vaginal delivery. Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.
## 149 Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.
## 150 Stab wound, left posterolateral chest. Closure of stab wound.
## 151 Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.
## 152 Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.
## 153 Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.
## 154 Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.
## 155 Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.
## 156 Spermatocelectomy and orchidopexy
## 157 Consult and Spinal fluid evaluation in a 15-day-old
## 158 Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.
## 159 SPARC suburethral sling due to stress urinary incontinence.
## 160 Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.
## 161 The skin biopsy was performed on the right ankle and right thigh. The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.
## 162 Functional endoscopic sinus surgery, excision of nasopharyngeal mass via endoscopic technique, and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.
## 163 Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus, transconjunctival exploration of orbital floor, open reduction of nasal septum and nasal pyramid fracture with osteotomy.
## 164 Left spermatocelectomy/epididymectomy and bilateral partial vasectomy. Left spermatocele and family planning.
## 165 Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.
## 166 Right shockwave lithotripsy, cystoscopy, and stent removal x2.
## 167 Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.
## 168 Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder.
## 169 Endoscopic proximal shunt revision.
## 170 Bilateral endoscopic proximal shunt revision and a distal shunt revision.
## 171 Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.
## 172 Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea.
## 173 Excision of sebaceous cyst, right lateral eyebrow.
## 174 Open septorhinoplasty with placement of bilateral spreader grafts. Bilateral lateral osteotomies.
## 175 Left scrotal exploration with detorsion. Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.
## 176 Scleral buckle opening under local anesthesia.
## 177 Selective coronary angiography, coronary angioplasty. Acute non-ST-elevation MI.
## 178 Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.
## 179 Placement of Scott cannula, right lateral ventricle
## 180 Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.
## 181 Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.
## 182 Removal of infected sebaceous cyst, right neck.
## 183 Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.
## 184 Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.
## 185 Ligation and stripping of left greater saphenous vein to the level of the knee. Stripping of multiple left lower extremity varicose veins. Varicose veins.
## 186 Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot.
## 187 Scleral Buckle opening under general anesthesia.
## 188 Sterilization candidate. Cervical dilatation and laparoscopic bilateral partial salpingectomy. A 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.
## 189 Stage IV necrotic sacral decubitus. Debridement of stage IV necrotic sacral decubitus.
## 190 Repair of ruptured globe with repositing of uveal tissue - Sample/Template.
## 191 Laparoscopic right salpingooophorectomy. Right pelvic pain and ovarian mass. Right ovarian cyst with ovarian torsion.
## 192 Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.
## 193 Repair of ruptured globe involving posterior sclera - Sample/Template.
## 194 Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.
## 195 Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease.
## 196 Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy.
## 197 Ruptured globe with full-thickness corneal laceration repair - Sample/Template.
## 198 Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus.
## 199 Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.
## 200 Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.
## 201 Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.
## 202 Repeat cesarean section and bilateral tubal ligation.
## 203 Cadaveric renal transplant to right pelvis - endstage renal disease.
## 204 Acute lymphocytic leukemia in remission, removal of venous port.
## 205 Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.
## 206 Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.
## 207 Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.
## 208 Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.
## 209 Bilateral rectus recession with the microscopic control, 8 mm, both eyes.
## 210 The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.
## 211 Radioactive plaque macular edema. Removal of radioactive plaque, right eye with lateral canthotomy. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.
## 212 Closure of rectovaginal fistula, transperineal approach
## 213 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.
## 214 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.
## 215 Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
## 216 Modified radical mastectomy. An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site. The skin incision was carried down to the subcutaneous fat but no further.
## 217 Invasive carcinoma of left breast. Left modified radical mastectomy.
## 218 Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.
## 219 Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).
## 220 Worrisome skin lesion. A punch biopsy of the worrisome skin lesion was obtained. Lesion was removed.
## 221 Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy
## 222 Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.
## 223 Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.
## 224 Punch biopsy of right upper chest skin lesion.
## 225 Macular edema, right eye. Insertion of radioactive plaque, right eye with lateral canthotomy. The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron. The placement was confirmed with indirect ophthalmoscopy.
## 226 Radical retropubic prostatectomy, robotic assisted and bladder suspension. Adenocarcinoma of the prostate.
## 227 Open radical retropubic prostatectomy with bilateral lymph node dissection.
## 228 Radical retropubic nerve-sparing prostatectomy without lymph node dissection.
## 229 Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer.
## 230 The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.
## 231 Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer.
## 232 Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.
## 233 Insertion of Port-A-Cath via left subclavian vein using fluoroscopy in a patient with renal cell carcinoma.
## 234 Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.
## 235 Right subclavian Port-a-Cath insertion in a patient with bilateral breast carcinoma.
## 236 Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding.
## 237 The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.
## 238 Placement of a Port-A-Cath under fluoroscopic guidancein a patient with anal cancer.
## 239 Port insertion through the right subclavian vein percutaneously under radiological guidance. Metastatic carcinoma of the bladder and bowel obstruction.
## 240 Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.
## 241 Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.
## 242 Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.
## 243 Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.
## 244 Closed reduction and pinning of the right ulna with placement of a long-arm cast.
## 245 Plantar fascitis, left foot. Partial plantar fasciotomy.
## 246 Chest tube talc pleurodesis of the right chest.
## 247 Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.
## 248 A 44-year-old, 250-pound male presents with extreme pain in his left heel.
## 249 External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.
## 250 Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.
## 251 Revision and in situ pinning of the right hip.
## 252 Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.
## 253 Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.
## 254 Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.
## 255 Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.
## 256 Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.
## 257 Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.
## 258 PICC line insertion
## 259 Phacoemulsification with posterior chamber intraocular lens implant in the right eye.
## 260 Phacoemulsification of cataract, extraocular lens implant in left eye.
## 261 Phacoemulsification with posterior chamber intraocular lens insertion.
## 262 Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.
## 263 Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.
## 264 Phacoemulsification of cataract and posterior chamber lens implant, right eye.
## 265 Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.
## 266 Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. Cataract, right eye.
## 267 Phacoemulsification with intraocular lens placement. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.
## 268 Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. A wire lid speculum was inserted to keep the eye open and the eye rotated downward.
## 269 Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant.
## 270 Visually significant nuclear sclerotic cataract, right eye. Phacoemulsification with posterior chamber intraocular lens implantation, right eye.
## 271 Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.
## 272 Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.
## 273 Cataract, nuclear sclerotic, right eye. Phacoemulsification with intraocular lens implantation, right eye.
## 274 Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.
## 275 Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.
## 276 Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700. Nonfunctioning inflatable penile prosthesis and Peyronie's disease.
## 277 A 14-year-old young lady is in the renal failure and in need of dialysis.
## 278 Permacath placement - renal failure.
## 279 Phacoemulsification with posterior chamber intraocular lens - Sample/Template.
## 280 Nuclear sclerotic cataract, right eye. Kelman phacoemulsification with posterior chamber intraocular lens, right eye.
## 281 Excision of penile skin bridges about 2 cm in size.
## 282 Parotidectomy procedure
## 283 Pelvic laparotomy, lysis of pelvic adhesions, and left salpingooophorectomy with insertion of Pain-Buster Pain Management System.
## 284 Percutaneous endoscopic gastrostomy tube. Protein-calorie malnutrition. The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.
## 285 Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.
## 286 Open repair of right pectoralis major tendon. Right pectoralis major tendon rupture. On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.
## 287 Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.
## 288 Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead. Right ventricular pacemaker lead placement and lead revision.
## 289 Coil embolization of patent ductus arteriosus.
## 290 Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee.
## 291 Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.
## 292 Paracentesis. A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.
## 293 Ultrasound-Guided Paracentesis for Ascites
## 294 Reduction of paraphimosis.
## 295 DDDR permanent pacemaker. Tachybrady syndrome. A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.
## 296 Insertion of transvenous pacemaker for tachybrady syndrome
## 297 Pacemaker ICD interrogation. Severe nonischemic cardiomyopathy with prior ventricular tachycardia.
## 298 Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.
## 299 Single chamber pacemaker implantation. Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.
## 300 Implantation of a dual chamber permanent pacemaker
## 301 Implantation of a single-chamber pacemaker. Fluoroscopic guidance for implantation of single-chamber pacemaker.
## 302 Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction.
## 303 Open reduction and internal fixation of left distal radius.
## 304 OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis.
## 305 Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius.
## 306 Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.
## 307 Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.
## 308 Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.
## 309 Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.
## 310 Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture. Closed reduction and screw fixation of right femoral neck fracture. Retrograde femoral nail using a striker T2 retrograde nail. Irrigation and debridement of knee and elbow abrasions.
## 311 Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3.
## 312 Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint.
## 313 Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.
## 314 Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.
## 315 Open reduction and internal fixation of left tibia.
## 316 Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.
## 317 Orchiopexy & inguinal herniorrhaphy.
## 318 Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.
## 319 Bilateral orchiopexy. This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.
## 320 Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.
## 321 Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.
## 322 Right orchiopexy and right inguinal hernia repair.
## 323 Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.
## 324 Right undescended testicle. Orchiopexy & Herniorrhaphy.
## 325 Left facial cellulitis and possible odontogenic abscess. Attempted incision and drainage (I&D) of odontogenic abscess.
## 326 Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.
## 327 Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.
## 328 Left orchiopexy. Ectopic left testis. The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.
## 329 Bilateral scrotal orchiectomy
## 330 Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.
## 331 Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.
## 332 Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.
## 333 Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.
## 334 Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy
## 335 Right radical nephrectomy and assisted laparoscopic approach.
## 336 Transplant nephrectomy after rejection of renal transplant
## 337 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.
## 338 Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.
## 339 Laparoscopic right partial nephrectomy due to right renal mass.
## 340 Laparoscopic right radical nephrectomy due to right renal mass.
## 341 Excision of neuroma, third interspace, left foot. Morton's neuroma, third interspace, left foot.
## 342 Needle-localized excisional biopsy, left breast. The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast. She had no palpable mass on physical exam. She does have significant family history with two daughters having breast cancer.
## 343 Stage I and II neuromodulator.
## 344 Needle-localized excisional biopsy of the left breast. Left breast mass with abnormal mammogram. The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.
## 345 Left partial nephrectomy due to left renal mass.
## 346 Left laparoscopic hand-assisted nephrectomy.
## 347 Malignant mass of the left neck, squamous cell carcinoma. Left neck mass biopsy and selective surgical neck dissection, left.
## 348 Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate. Nasal septal deviation with bilateral inferior turbinate hypertrophy. Tonsillitis with hypertrophy. Edema to the uvula and soft palate.
## 349 Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.
## 350 Left neck dissection. Metastatic papillary cancer, left neck. The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.
## 351 Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.
## 352 Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates. Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.
## 353 Bilateral nasolacrimal probing. Tearing, eyelash encrustation with probable tear duct obstruction bilateral. Distal nasolacrimal duct stenosis with obstruction, left and right eye
## 354 Bilateral myringotomies with insertion of Santa Barbara T-tube.
## 355 Open reduction, nasal fracture with nasal septoplasty.
## 356 Bilateral myringotomies and insertion of Shepard grommet draining tubes.
## 357 Removal of the old right pressure equalizing tube. Myringotomy with placement of a left pressure equalizing tube.
## 358 Multiple stent placements with Impella circulatory assist device.
## 359 Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.
## 360 Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.
## 361 Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band. Posterior leaflet abscess resection.
## 362 Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.
## 363 Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder. Partial rotator cuff tear with impingement syndrome. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.
## 364 Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.
## 365 Right middle ear exploration with a Goldenberg TORP reconstruction.
## 366 Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap. Adenocarcinoma of the prostate.
## 367 Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy.
## 368 Rhabdomyosarcoma of the left orbit. Left subclavian vein MediPort placement. Needs chemotherapy.
## 369 Right nodular malignant mesothelioma.
## 370 Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.
## 371 Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.
## 372 Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee. Patellar chondroplasty. Lateral femoral chondroplasty. Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,
## 373 Right pleural effusion and suspected malignant mesothelioma.
## 374 Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy.
## 375 Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass.
## 376 The patient had undergone mitral valve repair about seven days ago.
## 377 Mediastinal exploration and delayed primary chest closure. The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.
## 378 Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
## 379 Excision of soft tissue mass, right foot. The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.
## 380 An example/template for meatotomy.
## 381 Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.
## 382 Bilateral reduction mammoplasty for bilateral macromastia
## 383 An example/template for meatoplasty.
## 384 Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.
## 385 Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex.
## 386 Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.
## 387 Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.
## 388 Lysis of pelvic adhesions. The patient had an 8 cm left ovarian mass. The mass was palpable on physical examination and was tender. She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.
## 389 Sentinel lymph node biopsy. Ultrasound-guided lumpectomy with intraoperative ultrasound.
## 390 Left axillary lymph node excisional biopsy. Left axillary adenopathy.
## 391 Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain.
## 392 Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.\r\n
## 393 Possible CSF malignancy. This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak.
## 394 Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.
## 395 Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.
## 396 Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.
## 397 Lumbar puncture with moderate sedation.
## 398 Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.
## 399 Microscopic lumbar discectomy, left L5-S1. Extruded herniated disc, left L5-S1. Left S1 radiculopathy (acute). Morbid obesity.
## 400 Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.
## 401 Primary low transverse cervical cesarean section. Intrauterine pregnancy at 38 weeks and malpresentation. A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g. No nuchal cord. No meconium. Normal uterus, fallopian tubes, and ovaries.
## 402 Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization. Intrauterine pregnancy at 35-1/7. Rh isoimmunization. Suspected fetal anemia. Desires permanent sterilization.
## 403 Primary low-transverse C-section. Postdates pregnancy, failure to progress, meconium stained amniotic fluid.
## 404 Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.
## 405 Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at term with previous cesarean section. Desires permanent sterilization. Macrosomia.
## 406 Repeat low-transverse cesarean section via Pfannenstiel incision. Intrauterine pregnancy at 39 and 1/7th weeks. Previous cesarean section, refuses trial of labor. Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.
## 407 Primary low transverse cervical cesarean section. Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.
## 408 Primary low transverse cesarean section via Pfannenstiel incision. Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.
## 409 Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.
## 410 Primary cesarean section by low-transverse incision. Term pregnancy, nonreassuring fetal heart tracing.
## 411 A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.
## 412 Primary low-transverse cesarean section.
## 413 VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.
## 414 Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.
## 415 Primary low segment cesarean section.
## 416 Right upper lung lobectomy. Mediastinal lymph node dissection
## 417 Left lower lobectomy.
## 418 Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.\r\n
## 419 Closed reduction and placement of long-arm cast.
## 420 Excision of lipoma, left knee. A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.
## 421 Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.
## 422 Intramuscular lipoma, right upper extremity. Excision of intramuscular lipoma with flap closure.
## 423 Percutaneous liver biopsy. With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.
## 424 Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.
## 425 Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin. Repair of lateral meniscus using two fast fixed meniscal repair sutures. Partial medial meniscectomy. Partial chondroplasty of patella. Lateral retinacular release. Open medial plication as well of the right knee.
## 426 Ligament reconstruction and tendon interposition arthroplasty of right wrist.
## 427 Repair of upper lid canalicular laceration - Sample/Template.
## 428 Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping. Hoarseness, bilateral true vocal cord lesions, and leukoplakia.
## 429 Lateral release with lengthening of the ECRB tendon. Lateral epicondylitis.
## 430 The patient needing to be reintubated due to a leaking ET tube. The patient is recently postoperative.
## 431 Cystopyelogram and laser vaporization of the prostate.
## 432 Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.
## 433 Left orchiectomy, scrotal exploration, right orchidopexy.
## 434 Carbon dioxide laser photo-ablation due to recurrent dysplasia of vulva.
## 435 LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.
## 436 Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.
## 437 Exploratory laparotomy and right salpingectomy.
## 438 Diagnostic laparoscopy and rigid sigmoidoscopy. Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.
## 439 Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.
## 440 Laparotomy and myomectomy. Enlarged fibroid uterus and blood loss anemia. On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.
## 441 Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant. Chronic pelvic pain, probably secondary to endometriosis.
## 442 Laparoscopy with ablation of endometriosis. Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.
## 443 Laparoscopic supracervical hysterectomy. A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.
## 444 Diagnostic laparoscopy and laparoscopic appendectomy. Right lower quadrant abdominal pain, rule out acute appendicitis.
## 445 Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case.
## 446 Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.
## 447 Diagnostic laparoscopy and drainage of cyst.
## 448 Examination under anesthesia and laparoscopic right orchiopexy.
## 449 Laparoscopy with left salpingo-oophorectomy. Left adnexal mass/ovarian lesion. The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.
## 450 Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.
## 451 Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.
## 452 Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty. Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.
## 453 Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.
## 454 Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.
## 455 Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.
## 456 Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.
## 457 Symptomatic cholelithiasis. Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970). The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her.
## 458 Laparoscopic cholecystectomy. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.
## 459 Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.
## 460 Laparoscopic cholecystectomy with cholangiogram. Acute gangrenous cholecystitis with cholelithiasis. The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.
## 461 Cholecystitis and cholelithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.
## 462 Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.
## 463 Cholelithiasis; possible choledocholithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.
## 464 Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.
## 465 Standard Laparoscopic Cholecystectomy Operative Note.
## 466 Biliary colic. Laparoscopic cholecystectomy. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope.
## 467 Acute cholecystitis. Laparoscopic cholecystectomy. The abdominal area was prepped and draped in the usual sterile fashion. A small skin incision was made below the umbilicus. It was carried down in the transverse direction on the side of her old incision. It was carried down to the fascia.
## 468 Chronic cholecystitis without cholelithiasis.
## 469 Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis.
## 470 Laparoscopic cholecystectomy.
## 471 Appendicitis. Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants.
## 472 Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants. Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.
## 473 Laparoscopic appendectomy. The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis.
## 474 Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions.
## 475 Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.
## 476 Ruptured appendicitis.
## 477 Laparoscopic appendectomy. Acute appendicitis.
## 478 Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.
## 479 Acute appendicitis with perforation. Laparoscopic appendectomy. A CT scan of abdomen showed evidence of appendicitis with perforation.
## 480 Appendicitis. Laparoscopic appendectomy. CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.
## 481 Patient status post lap band placement.
## 482 Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.
## 483 L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.
## 484 Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. Vertebroplasties at T7 and T9 with insertion of prosthetic device. Fracture of the T8 vertebra and T9 vertebra.
## 485 Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1.
## 486 Left knee arthroscopy with lateral capsular release.
## 487 Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.
## 488 Left medial compartment osteoarthritis of the knee. Left unicompartmental knee replacement.
## 489 Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized.
## 490 Revision right total knee arthroplasty. Right failed total knee arthroplasty.
## 491 KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy.
## 492 Arthroscopic procedure of the knee.
## 493 Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP. Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.
## 494 Procedure note on Keller Bunionectomy
## 495 Left below-the-knee amputation. Dressing change, right foot.
## 496 Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage
## 497 Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.
## 498 Bilateral degenerative arthritis of the knees. Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.
## 499 Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.
## 500 Debridement left ischial ulcer.
## 501 Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail. Left tibial shaft fracture status post gunshot wound.
## 502 Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.
## 503 Inguinal orchiopexy procedure.
## 504 Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision. Recurrent right inguinal hernia, as well as phimosis.
## 505 Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter.
## 506 Bassini inguinal herniorrhaphy. A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.
## 507 Direct inguinal hernia. Rutkow direct inguinal herniorrhaphy. A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.
## 508 Left inguinal herniorrhaphy, modified Bassini. Left inguinal hernia, direct.
## 509 Repair of left inguinal hernia indirect. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.
## 510 Inguinal herniorrhaphy. A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.
## 511 Left direct and indirect inguinal hernia. Repair of left inguinal hernia with Prolene mesh. The patient was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.
## 512 Right inguinal hernia. Right inguinal hernia repair. The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.
## 513 Direct right inguinal hernia. Marlex repair of right inguinal hernia.
## 514 Right inguinal hernia. Right direct inguinal hernia repair with PHS mesh system. The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion. An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.
## 515 A 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia, taken to the operating room for inguinal hernia repair.
## 516 Bilateral inguinal hernia. Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump.
## 517 Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally.
## 518 Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. \r\n
## 519 This patient has reoccurring ingrown infected toenails.
## 520 Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.
## 521 Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.
## 522 Autologous iliac crest bone graft to maxilla and mandible under general anesthetic. Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction.
## 523 Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.
## 524 Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.
## 525 Perirectal abscess. Incision and drainage (I&D) of perirectal abscess.
## 526 Incision and drainage (I&D) with primary wound closure of scalp lacerations. The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. The patient was taken to the operating room for an I&D of the lacerations with wound closure.
## 527 Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.
## 528 Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.
## 529 Incision and drainage of left neck abscess.
## 530 Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast.
## 531 Incision and drainage (I&D) of gluteal abscess. Removal of pigtail catheter. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.
## 532 Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.
## 533 Incision and drainage of right buccal space abscess and teeth extraction.
## 534 Placement of right external iliac artery catheter via left femoral approach, arteriography of the right iliac arteries, primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon, open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.
## 535 Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid. Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.
## 536 Incision and drainage (I&D) of buttock abscess.
## 537 Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.
## 538 Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.
## 539 Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.
## 540 Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).
## 541 Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.
## 542 Pelvic tumor, cystocele, rectocele, and uterine fibroid. Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.
## 543 Laparoscopic supracervical hysterectomy. Menorrhagia and dysmenorrhea.
## 544 Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.
## 545 Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.
## 546 Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.
## 547 Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.
## 548 Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.
## 549 Wide Local Excision of the Vulva. Radical anterior hemivulvectomy. Posterior skinning vulvectomy.
## 550 Laparoscopic left inguinal hernia repair.
## 551 Placement of a subclavian single-lumen tunneled Hickman central venous catheter. Surgeon-interpreted fluoroscopy.
## 552 Inguinal hernia hydrocele repair.
## 553 Left hydrocelectomy. This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum.
## 554 Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.
## 555 Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.
## 556 Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.
## 557 Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.
## 558 Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure.
## 559 Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture.
## 560 Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.
## 561 Left heart catheterization, coronary angiography, left ventriculography. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.
## 562 Left heart catheterization, left ventriculography, selective coronary angiography.
## 563 Exploratory laparotomy, lysis of adhesions, and right hemicolectomy. Right colon cancer, ascites, and adhesions.
## 564 Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus.
## 565 Left heart catheterization with left ventriculography and selective coronary angiography. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function. Frequent PVCs. Metabolic syndrome.
## 566 Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.
## 567 Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.
## 568 Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.
## 569 Selective coronary angiography, left heart catheterization, and left ventriculography. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.
## 570 Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.
## 571 Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.
## 572 Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.
## 573 Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
## 574 Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test.
## 575 Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.
## 576 Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.
## 577 Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.
## 578 Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo.
## 579 Right heart catheterization. Refractory CHF to maximum medical therapy.
## 580 Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.
## 581 Left distal medial hamstring release.
## 582 Right and left heart catheterization, coronary angiography, left ventriculography.
## 583 Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.
## 584 Hardware removal in the left elbow.
## 585 Hardware removal, right ulnar
## 586 Chest pain and non-Q-wave MI with elevation of troponin I only. Left heart catheterization, left ventriculography, and left and right coronary arteriography.
## 587 Left heart catheterization and bilateral selective coronary angiography. The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.
## 588 Pyogenic granuloma, left lateral thigh. Excision of recurrent pyogenic granuloma.
## 589 <NA>
## 590 Gastroscopy. A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.
## 591 Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection.
## 592 Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.
## 593 Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.
## 594 Full mouth dental rehabilitation in the operative room under general anesthesia.
## 595 Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.
## 596 Full mouth dental rehabilitation in the operating room under general anesthesia.
## 597 Dysphagia, possible stricture. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.
## 598 Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms.
## 599 Cystoscopy and removal of foreign objects from the urethra.
## 600 Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome.
## 601 Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.
## 602 Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.
## 603 Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.
## 604 Microscopic hematuria with lateral lobe obstruction, mild.
## 605 Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.
## 606 Removal of foreign body of right thigh. Foreign body of the right thigh, sewing needle.
## 607 Flexor carpi radialis and palmaris longus repair. Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.
## 608 Flexible nasal laryngoscopy. Foreign body, left vallecula at the base of the tongue. Airway is patent and stable.
## 609 CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.
## 610 Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.
## 611 Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.
## 612 Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.
## 613 Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.
## 614 Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.
## 615 Flexible bronchoscopy to evaluate the airway (chronic wheezing).
## 616 Flexible sigmoidoscopy due to rectal bleeding.
## 617 Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe. Right hyoid mass, rule out carcinomatosis. Chronic obstructive pulmonary disease. Changes consistent with acute and chronic bronchitis.
## 618 Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.
## 619 Fiberoptic nasolaryngoscopy. Dysphagia with no signs of piriform sinus pooling or aspiration. Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.
## 620 Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.
## 621 Flexible Sigmoidoscopy.
## 622 Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.
## 623 Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain.
## 624 Incompetent glottis. Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.
## 625 Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg.
## 626 Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage. Bilateral upper lobe cavitary lung masses. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout.
## 627 Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability.
## 628 External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation.
## 629 Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.
## 630 Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.
## 631 Left supraorbital deep complex facial laceration measuring 6x2 cm. Plastic closure of deep complex facial laceration measuring 6x2 cm. The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead. The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site.
## 632 Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.
## 633 Exploratory laparotomy. Extensive lysis of adhesions. Right salpingo-oophorectomy. Pelvic mass, suspected right ovarian cyst.
## 634 Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.
## 635 Left little finger extensor tendon laceration. Repair of left little extensor tendon.
## 636 Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess.
## 637 Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia.
## 638 Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.
## 639 Re-excision of squamous cell carcinoma site, right hand.
## 640 Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures
## 641 Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.
## 642 Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.
## 643 Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage.
## 644 Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction.
## 645 Esophagoscopy with removal of foreign body. Esophageal foreign body, no associated comorbidities are noted.
## 646 Excision of bilateral chronic hydradenitis.
## 647 Esophagogastroduodenoscopy with pseudo and esophageal biopsy. Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.
## 648 Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.
## 649 Esophageal foreign body, US penny. Esophagoscopy with foreign body removal. The patient had a penny lodged in the proximal esophagus in the typical location.
## 650 Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement. Malnutrition and dysphagia with two antral polyps and large hiatal hernia.
## 651 Esophagogastroduodenoscopy with photo. Insertion of a percutaneous endoscopic gastrostomy tube. Neuromuscular dysphagia. Protein-calorie malnutrition.
## 652 Positive peptic ulcer disease. Gastritis. Esophagogastroduodenoscopy with photography and biopsy. The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.
## 653 Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.
## 654 Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp. Esophagogastroduodenoscopy with photos and antral biopsy.
## 655 Esophagogastroduodenoscopy. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.
## 656 Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.
## 657 Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal.
## 658 Esophagogastroduodenoscopy performed in the emergency department.
## 659 Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.
## 660 Esophagogastroduodenoscopy with biopsy.
## 661 Esophagogastroduodenoscopy, photography, and biopsy. Gastroesophageal reflux disease, hiatal hernia, and enterogastritis.
## 662 Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy.
## 663 Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.
## 664 Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia
## 665 Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.
## 666 Direct laryngoscopy and esophagoscopy with removal of foreign body
## 667 Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. Nausea and vomiting and upper abdominal pain.
## 668 Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.
## 669 Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar.
## 670 Epigastric herniorrhaphy. Epigastric hernia.
## 671 Epididymectomy
## 672 Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.
## 673 A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.
## 674 Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia.
## 675 The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.
## 676 Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction.
## 677 Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.
## 678 Upper endoscopy with biopsy. The patient admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.
## 679 Upper gastrointestinal endoscopy.
## 680 Normal upper GI endoscopy.
## 681 Intermittent rectal bleeding with abdominal pain.
## 682 Endoscopic carpal tunnel release. Left carpal tunnel syndrome.
## 683 Upper endoscopy, patient with dysphagia.
## 684 Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.
## 685 Patient with dysphagia.
## 686 Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.
## 687 Melena and solitary erosion over a fold at the GE junction, gastric side.
## 688 Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.
## 689 Left elbow manipulation and hardware removal of left elbow.
## 690 Emergency cesarean section.
## 691 Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.
## 692 Esophagogastroduodenoscopy with biopsy. Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.
## 693 Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.
## 694 Common description of EGD
## 695 EGD with dilation for dysphagia.
## 696 Common description of EGD.
## 697 EGD with photos and biopsies. This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. She has a previous history of hiatal hernia. She was on Prevacid currently.
## 698 EGD with PEG tube placement using Russell technique. Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.
## 699 Common description of EGD.
## 700 EGD and colonoscopy. Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.
## 701 Esophagogastroduodenoscopy and colonoscopy with polypectomy
## 702 Common description of EGD.
## 703 Problems with dysphagia to solids and had food impacted in the lower esophagus. Upper endoscopy to evaluate the esophagus.
## 704 Esophagogastroduodenoscopy, patient with dysphagia.
## 705 Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.
## 706 Right ear examination under anesthesia. Right tympanic membrane perforation along with chronic otitis media.
## 707 Dual Chamber ICD Implantation, fluoroscopy, defibrillation threshold testing, venography.
## 708 Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.
## 709 Dual chamber generator replacement. The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.
## 710 Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
## 711 Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.
## 712 Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.
## 713 Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.
## 714 Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment.
## 715 Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port.
## 716 Direct laryngoscopy and bronchoscopy.
## 717 Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.
## 718 Traumatic injury to bilateral upper extremities. Dressing change under anesthesia. This 6 year old was involved in a traumatic accident. She presents today for evaluation and dressing change.
## 719 Fractional dilatation and curettage
## 720 Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs
## 721 Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue.
## 722 Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.
## 723 She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.
## 724 Dental restorations and extractions. Dental caries. He has had multiple severe carious lesions that warrant multiple extractions at this time.
## 725 An 83-year-old diabetic female presents today stating that she would like diabetic foot care.
## 726 Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.
## 727 The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.
## 728 Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.
## 729 Dental prophylaxis under general anesthesia.
## 730 Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder. Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.
## 731 Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started.
## 732 Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.
## 733 Pitocin was started quickly to allow for delivery as quickly as possible. Baby was delivered with a single maternal pushing effort with retraction by the forceps.
## 734 Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing.
## 735 The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.
## 736 The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.
## 737 Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum.
## 738 Spontaneous controlled sterile vaginal delivery performed without episiotomy.
## 739 Incision and drainage with extensive debridement, left shoulder. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component). Implantation of antibiotic beads, left shoulder.
## 740 Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.
## 741 She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.
## 742 Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.
## 743 Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.
## 744 Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.
## 745 Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area. Pannus and left peritoneal specimen sent to Pathology.
## 746 DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,
## 747 Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum.
## 748 Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.
## 749 Complex right lower quadrant mass with possible ectopic pregnancy. Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.
## 750 Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis. Carpal tunnel release and de Quervain's release. A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis.
## 751 Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.
## 752 Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.
## 753 D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.\r\n6. Grade 1+ rectocele.
## 754 Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.
## 755 Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.
## 756 Cystourethroscopy and tTransurethral resection of prostate (TURP). Urinary retention and benign prostate hypertrophy. This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.
## 757 Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye.
## 758 Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.
## 759 Benign prostatic hypertrophy and urinary retention. Cystourethroscopy and transurethral resection of prostate (TURP).
## 760 Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration. Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.
## 761 Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.
## 762 Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.
## 763 Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.
## 764 Cystoscopy & Visual urethrotomy procedure
## 765 Cystoscopy. Transurethral resection of the prostate.
## 766 Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.
## 767 Right lower pole renal stone and possibly infected stent. Cysto stent removal.
## 768 Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.
## 769 Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.
## 770 Cystoscopy and Bladder biopsy with fulguration. History of bladder tumor with abnormal cytology and areas of erythema.
## 771 Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.
## 772 Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.
## 773 CT of abdomen with and without contrast. CT-guided needle placement biopsy.
## 774 Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.
## 775 Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy. Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.
## 776 Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.
## 777 CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.
## 778 Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.
## 779 Left temporal craniotomy and removal of brain tumor.
## 780 Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.
## 781 Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.
## 782 Left retrosigmoid craniotomy and excision of acoustic neuroma.
## 783 Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.
## 784 Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.
## 785 Cystoscopy, cryosurgical ablation of the prostate.
## 786 Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.
## 787 Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage. Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.
## 788 Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.
## 789 Anterior cranial vault reconstruction with fronto-orbital bar advancement.
## 790 Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.
## 791 Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage. The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.
## 792 Lateral and plantar condylectomy, fifth left metatarsal.
## 793 Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.
## 794 Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.
## 795 Cervical cone biopsy, dilatation & curettage
## 796 Colonoscopy with random biopsies and culture.
## 797 Colpocleisis and rectocele repair.
## 798 Completion thyroidectomy with limited right paratracheal node dissection.
## 799 Colonoscopy with photos. The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion.
## 800 A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.
## 801 A woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.
## 802 Small internal hemorrhoids and Ileal colonic anastomosis.
## 803 The patient with a recent change in bowel function and hematochezia.
## 804 Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.
## 805 Total colonoscopy with biopsy and snare polypectomy.
## 806 Common description of colonoscopy
## 807 Common description of colonoscopy
## 808 Common description of colonoscopy
## 809 Common description of colonoscopy
## 810 Common description of colonoscopy
## 811 Colonoscopy, conscious sedation, and snare polypectomy.
## 812 Patient with history of adenomas and irregular bowel habits.
## 813 Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.\r\n
## 814 Colonoscopy to screen for colon cancer
## 815 Patient with history of polyps.
## 816 Total colonoscopy and polypectomy
## 817 Colonoscopy due to hematochezia and personal history of colonic polyps.
## 818 Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.
## 819 Colonoscopy - Diarrhea, suspected irritable bowel
## 820 Colonoscopy to evaluate prior history of neoplastic polyps.
## 821 Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy. Colon cancer screening. Family history of colon polyps.
## 822 Possible inflammatory bowel disease. Polyp of the sigmoid colon.. Total colonoscopy with photography and polypectomy.
## 823 Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy.
## 824 Colonoscopy. Rectal bleeding and perirectal abscess. Normal colonoscopy to the terminal ileum. Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.
## 825 Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos. The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.
## 826 History of polyps. Total colonoscopy and photography. Normal colonoscopy, left colonic diverticular disease. 3+ benign prostatic hypertrophy.
## 827 Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.
## 828 Screening colonoscopy. Tiny polyps. If adenomatous, repeat exam in five years.
## 829 Colonoscopy in a patient with prior history of anemia and abdominal bloating.
## 830 Colonoscopy. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum.
## 831 Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.
## 832 Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids.
## 833 Colonoscopy. Change in bowel habits and rectal prolapse. Normal colonic mucosa to the cecum.
## 834 Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.
## 835 Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.
## 836 Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.
## 837 Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.
## 838 Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.
## 839 Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.
## 840 Collar Tubes technique
## 841 Iron deficiency anemia. Diverticulosis in the sigmoid.
## 842 Closure of multiple complex lacerations. Multiple complex lacerations of the periorbital area.
## 843 Repair of bilateral cleft of the palate with vomer flaps.
## 844 Trimalleolar ankle fracture and dislocation right ankle. A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well. Closed open reduction and internal fixation of right ankle.
## 845 Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.
## 846 Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted.
## 847 Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.
## 848 Bilateral open mandible fracture, open left angle and open symphysis fracture. Closed reduction of mandible fracture with MMF.
## 849 Newborn circumcision. The penile foreskin was removed using Gomco.
## 850 Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear.
## 851 Circumcision and release of ventral chordee.
## 852 Normal penis. The foreskin was normal in appearance and measured 1.6 cm. There was no bleeding at the circumcision site.
## 853 Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.
## 854 Circumcision. A dorsal slit was made, and the prepuce was dissected away from the glans penis.
## 855 Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.
## 856 Circumcision procedure in a baby
## 857 Circumcision in an older person
## 858 Normal Circumcision
## 859 Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.\r\n
## 860 Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.
## 861 Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.
## 862 Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis.
## 863 Circumcision procedure (neotal)
## 864 The patient had spraying of urine and ballooning of the foreskin with voiding.
## 865 Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.
## 866 Open cholecystectomy (attempted laparoscopic cholecystectomy).
## 867 Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.
## 868 Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.
## 869 Laparoscopic cholecystectomy with cholangiogram.
## 870 Left pleural effusion, parapneumonic, loculated. Left chest tube placement.
## 871 Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.
## 872 Removal of chest wall mass. The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.
## 873 Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.
## 874 Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion.
## 875 Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound.
## 876 Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis. Term pregnancy and desires permanent sterilization.
## 877 Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity.
## 878 Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum.
## 879 Laparoscopic resection of cecal polyp. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.
## 880 Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.
## 881 Right subclavian triple lumen central line placement
## 882 Insertion of central venous line and arterial line and transesophageal echocardiography probe.
## 883 Central line insertion. Empyema thoracis and need for intravenous antibiotics.
## 884 Cauterization of epistaxis, left nasal septum. Fiberoptic nasal laryngoscopy. Atrophic dry nasal mucosa. Epistaxis. Atrophic laryngeal changes secondary to inhaled steroid use.
## 885 Ultrasound-guided placement of multilumen central venous line, left femoral vein.
## 886 Temporal cheek-neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.
## 887 Refractory priapism. Cavernosaphenous shunt. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed
## 888 Normal cataract surgery.
## 889 Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.
## 890 Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.
## 891 Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.
## 892 Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.
## 893 Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.
## 894 Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.
## 895 Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.
## 896 Carpal tunnel syndrome. Open carpal tunnel release. A longitudinal incision was made in line with the 4th ray. The dissection was carried down to the superficial aponeurosis, which was cut. The distal edge of the transverse carpal ligament was identified with a hemostat.
## 897 Right carpal tunnel release. Right carpal tunnel syndrome. This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.
## 898 Right carpal tunnel syndrome. Right carpal tunnel release.
## 899 Right open carpal tunnel release and cortisone injection, left carpal tunnel.
## 900 Bilateral open carpal tunnel release.
## 901 Carpal tunnel syndrome. Endoscopic carpal tunnel release. After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.
## 902 Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.
## 903 Endoscopic release of left transverse carpal ligament.
## 904 Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger.
## 905 Left endoscopic carpal tunnel release and endotracheal fasciotomy.
## 906 Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.
## 907 Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.
## 908 Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis.
## 909 Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.
## 910 Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation.
## 911 Cardioversion. Unsuccessful direct current cardioversion with permanent atrial fibrillation.
## 912 Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.
## 913 Left carotid endarterectomy with endovascular patch angioplasty. Critical left carotid stenosis. The external carotid artery was occluded at its origin. When the endarterectomy was performed, the external carotid artery back-bled nicely. The internal carotid artery had good backflow bleeding noted.
## 914 Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.
## 915 Left heart cardiac catheterization.
## 916 Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth.
## 917 Right carpal tunnel release.
## 918 Cardioversion. An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation
## 919 Cardiac catheterization and coronary intervention report.
## 920 Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.
## 921 White male with onset of chest pain, with history of on and off chest discomfort over the past several days.
## 922 Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.
## 923 Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.
## 924 Cardiac catheterization. Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.
## 925 Left Heart Catheterization. Chest pain, coronary artery disease, prior bypass surgery. Left coronary artery disease native. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. Native right coronary artery is patent, mild disease.
## 926 Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.
## 927 The patient with atypical type right arm discomfort and neck discomfort.
## 928 Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.
## 929 Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.
## 930 Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization.
## 931 Left cardiac catheterization with selective right and left coronary angiography. Post infarct angina.
## 932 Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.
## 933 Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery.
## 934 Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.
## 935 Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.
## 936 Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.
## 937 Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. Placement of a right femoral intraaortic balloon pump.
## 938 Coronary artery bypass grafting (CABG) x4. Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.
## 939 Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.
## 940 Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.
## 941 Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal.\r\n
## 942 Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.
## 943 Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.
## 944 Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.
## 945 A 60-year-old female presents today for care of painful calluses and benign lesions.
## 946 Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region and adjacent tissue transfer closure of the left supraclavicular grafting site
## 947 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.
## 948 Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.
## 949 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes.
## 950 Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.
## 951 Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.
## 952 Plastic piece foreign body in the right main stem bronchus. Rigid bronchoscopy with foreign body removal.
## 953 Bronchoscopy with brush biopsies. Persistent pneumonia, right upper lobe of the lung, possible mass.
## 954 Bronchoscopy with aspiration and left upper lobectomy. Carcinoma of the left upper lobe.
## 955 Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.
## 956 Diagnostic fiberoptic bronchoscopy.
## 957 Bronchoscopy brushings, washings and biopsies. Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.
## 958 Fiberoptic bronchoscopy with endobronchial biopsies. A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.
## 959 Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. Bilateral bronchopneumonia and empyema of the chest, left.
## 960 Bronchoscopy for hypoxia and increasing pulmonary secretions
## 961 Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.
## 962 Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.
## 963 Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin.
## 964 Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.
## 965 Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.
## 966 Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.
## 967 Right breast excisional biopsy with needle-localization. The patient is a 41-year-old female with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.
## 968 Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.
## 969 Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.
## 970 Bronchoscopy. Atelectasis and mucous plugging.
## 971 Excisional breast biopsy with needle localization. The skin overlying the needle tip was incised in a curvilinear fashion.
## 972 Needle localization and left breast biopsy for left breast mass.
## 973 Left excisional breast biopsy due to atypical ductal hyperplasia of left breast.
## 974 Excision of right breast mass. Right breast mass with atypical proliferative cells on fine-needle aspiration.
## 975 Brachytherapy, iodine-125 seed implantation, and cystoscopy.
## 976 Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.
## 977 Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.
## 978 Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.
## 979 Bilateral myringotomy tubes and adenoidectomy.
## 980 Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.
## 981 Lower lid blepharoplasty.
## 982 Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.
## 983 Blepharoplasty with direct brow repair.
## 984 Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.
## 985 Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.
## 986 Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.
## 987 Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.
## 988 Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.
## 989 Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.
## 990 Excisional biopsy of right cervical lymph node.
## 991 Blepharoplasty procedure
## 992 Closure of bladder laceration, during cesarean section.
## 993 Cystoscopy, cystocele repair, BioArc midurethral sling.
## 994 Bilateral vasovasostomy surgery sample.
## 995 Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures,
## 996 Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.
## 997 Desires permanent sterilization. Laparoscopic bilateral tubal occlusion with Hulka clips.
## 998 Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.
## 999 Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.
## 1000 3-1/2-year-old presents with bilateral scrotal swellings consistent with bilateral inguinal hernias.
## 1001 Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.
## 1002 Bilateral Myringotomy with placement of PE tubes
## 1003 Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.
## 1004 Ruptured distal biceps tendon, right elbow. Repair of distal biceps tendon, right elbow.
## 1005 Belly button piercing for insertion of belly button ring.
## 1006 Hematemesis in a patient with longstanding diabetes. Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis. Mallory-Weiss tear, successful BICAP cautery.
## 1007 Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants
## 1008 Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.
## 1009 Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.
## 1010 Excision of nasal tip basal carcinoma, previous positive biopsy.
## 1011 Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.
## 1012 Right basilic vein transposition. End-stage renal disease with need for a long-term hemodialysis access. Excellent flow through fistula following the procedure.
## 1013 Creation of autologous right brachiobasilic arteriovenous fistula - first stage.
## 1014 Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.
## 1015 Left forearm arteriovenous fistula between cephalic vein and radial artery.
## 1016 Creation of AV fistula, left wrist in the anatomic snuffbox.
## 1017 Creation of right brachiocephalic arteriovenous fistula.
## 1018 Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal. Excision of nerve lesion with implantation of the muscle belly of the left second interspace. Excision of nerve lesion in the left third interspace.\r\n
## 1019 Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.
## 1020 Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.
## 1021 Austin bunionectomy with internal screw fixation, first metatarsal, left foot.
## 1022 The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.
## 1023 Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint. Weil osteotomy with internal screw fixation, first right metatarsal. Arthroplasty, second right PIP joint.
## 1024 Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.
## 1025 Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.
## 1026 Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure.
## 1027 Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well. Chondromalacia of medial femoral condyle. Medial meniscal tear, left knee.
## 1028 Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.
## 1029 Diagnostic arthroscopy exam under anesthesia, left shoulder. Debridement of chondral injury, left shoulder. Debridement, superior glenoid, left shoulder. Arthrotomy. Bankart lesion repair. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).
## 1030 Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.
## 1031 Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.
## 1032 Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.
## 1033 Rotator cuff tear, right shoulder. Superior labrum anterior and posterior lesion (peel-back), right shoulder. Arthroscopy with arthroscopic SLAP lesion. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.
## 1034 Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.
## 1035 Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.
## 1036 Arthroscopy with arthroscopic subacromial decompression of the left shoulder. Impingement syndrome, left shoulder. Rule out superior labrum anterior and posterior lesion, left shoulder.
## 1037 Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.
## 1038 Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.
## 1039 Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.
## 1040 Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.
## 1041 Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.
## 1042 Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.
## 1043 Laparoscopic appendectomy. Acute appendicitis.
## 1044 Femoroacetabular impingement. Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.
## 1045 Laparoscopic appendectomy. Acute suppurative appendicitis. A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan.
## 1046 Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.
## 1047 Acute appendicitis, gangrenous. Appendectomy.
## 1048 Acute appendicitis and 29-week pregnancy. Appendectomy.
## 1049 Aortoiliac occlusive disease. Aortobifemoral bypass. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.
## 1050 Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication.
## 1051 Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.
## 1052 Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.
## 1053 Laparoscopic appendectomy and peritoneal toilet and photos. Pelvic inflammatory disease and periappendicitis.
## 1054 Appendicitis, nonperforated. Appendectomy. A transverse right lower quadrant incision was made directly over the point of maximal tenderness.
## 1055 Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.
## 1056 Dementia and aortoiliac occlusive disease bilaterally. Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.
## 1057 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.
## 1058 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.
## 1059 Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain.
## 1060 Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.
## 1061 C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.
## 1062 Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation
## 1063 Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.
## 1064 C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.
## 1065 Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.
## 1066 Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.
## 1067 Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.
## 1068 Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.
## 1069 Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.
## 1070 Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).
## 1071 Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.
## 1072 Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.
## 1073 Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.
## 1074 Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.
## 1075 Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.
## 1076 Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5.
## 1077 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.
## 1078 Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.\r\n7. Microscopic dissection.
## 1079 Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.
## 1080 Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant. Disc herniation with right arm radiculopathy.
## 1081 Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.
## 1082 C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.
## 1083 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.
## 1084 Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.
## 1085 Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.
## 1086 Adenotonsillectomy, primary, patient under age 12.
## 1087 Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.
## 1088 The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed.
## 1089 Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.
## 1090 Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization. Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.
## 1091 Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.
## 1092 Grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary - Omentectomy, pelvic lymph node dissection, and laparoscopy.
## 1093 Adenoidectomy procedure
## 1094 Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.
## 1095 Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed.
## 1096 Bilateral open Achilles lengthening with placement of short leg walking cast.
## 1097 Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.
## 1098 Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.
## 1099 Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.
## 1100 Excision of abscess, removal of foreign body. Repair of incisional hernia. Recurrent re-infected sebaceous cyst of abdomen. Abscess secondary to retained foreign body and incisional hernia.
## 1101 Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak. Diffuse intestinal and mesenteric lymphangiectasia.
## 1102 Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.
## 1103 Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.
## 1104 Ultrasound examination of the scrotum due to scrotal pain. Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed.
## 1105 X-RAY of the soft tissues of the neck.
## 1106 This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.
## 1107 Whole body radionuclide bone scan due to prostate cancer.
## 1108 A 27-year-old female with a size and date discrepancy.
## 1109 Pregnant female with nausea, vomiting, and diarrhea. OB ultrasound less than 14 weeks, transvaginal.
## 1110 Ultrasound - a 22-year-old pregnant female.
## 1111 Twin pregnancy with threatened preterm labor.
## 1112 A 37 year-old female with twin pregnancy with threatened premature labor.
## 1113 A 34-year old female with no fetal heart motion noted on office scan.
## 1114 Ultrasound of pelvis - menorrhagia.
## 1115 Transvaginal ultrasound to evaluate pelvic pain.
## 1116 OB Ultrasound - A 29-year-old female requests for size and date of pregnancy.
## 1117 Bilateral lower extremity ultrasound for deep venous thrombus.
## 1118 AP abdomen and ultrasound of kidney.
## 1119 Ultrasound left lower extremity, duplex venous, due to swelling and to rule out DVT. Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed.
## 1120 Bilateral carotid ultrasound to evaluate pain.
## 1121 Ultrasound OB - followup for fetal growth.
## 1122 Ultrasound of the right mandibular region.
## 1123 Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.
## 1124 Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe.
## 1125 Ultrasound Abdomen - elevated liver function tests.
## 1126 Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.
## 1127 Right and Left carotid ultrasound
## 1128 Ultrasound abdomen, complete
## 1129 Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.
## 1130 Transesophageal echocardiogram for aortic stenosis. Normal left ventricular size and function. Benign Doppler flow pattern. Doppler study essentially benign. Aorta essentially benign. Atrial septum intact. Study was negative.
## 1131 Left testicular swelling for one day. Testicular Ultrasound. Hypervascularity of the left epididymis compatible with left epididymitis. Bilateral hydroceles.
## 1132 Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.
## 1133 Transesophageal echocardiogram and direct current cardioversion.
## 1134 Transesophageal echocardiographic examination report. Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.
## 1135 Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function. Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.
## 1136 Pain. Three views of the right ankle. Three views of the right ankle are obtained.
## 1137 Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot.
## 1138 Right foot trauma. Three views of the right foot. Three views of the right foot were obtained.
## 1139 Chest pain, Chest wall tenderness occurred with exercise.
## 1140 Thallium stress test for chest pain.
## 1141 Stress test with Bruce protocol due to chest pain.
## 1142 Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction.
## 1143 Dobutrex stress test for abnormal EKG
## 1144 Dobutamine stress test for atrial fibrillation.
## 1145 Frontal and lateral views of the hip and pelvis.
## 1146 Stress test - Adenosine Myoview. Ischemic cardiomyopathy. Inferoseptal and apical transmural scar.
## 1147 HCT: SAH, Contusion, Skull fracture
## 1148 Chest, Single view post OP for ASD (Atrial Septal Defect).
## 1149 Single frontal view of the chest. Respiratory distress. The patient has a history of malrotation.
## 1150 Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.
## 1151 Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy
## 1152 Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.
## 1153 Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.
## 1154 Bilateral renal ultrasound.
## 1155 Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.
## 1156 Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.
## 1157 Prostate Brachytherapy - Prostate I-125 Implantation
## 1158 Right foot series after a foot injury.
## 1159 Ultrasound-Guided Paracentesis for Ascites
## 1160 Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.
## 1161 Nuclear cardiac stress report. Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.
## 1162 Whole body PET scanning.
## 1163 Nuclear medicine tumor localization, whole body - status post subtotal thyroidectomy for thyroid carcinoma.
## 1164 Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
## 1165 Resting Myoview perfusion scan and gated myocardial scan. Findings consistent with an inferior non-transmural scar
## 1166 MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.
## 1167 Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.
## 1168 Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.
## 1169 Patient with wrist pain and swelling, status post injury.
## 1170 Skull, complete, five images.
## 1171 MRI L-Spine - Bilateral lower extremity numbness
## 1172 Myocardial perfusion imaging - patient had previous abnormal stress test. Stress test with imaging for further classification of CAD and ischemia.
## 1173 The thoracic spine was examined in the AP, lateral and swimmer's projections.
## 1174 MRI T-spine and CXR - Aortic Dissection.
## 1175 A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.
## 1176 MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.
## 1177 MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.
## 1178 A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.
## 1179 MRI left shoulder.
## 1180 A 32-year-old male with shoulder pain.
## 1181 MRI of the Cervical, Thoracic, and Lumbar Spine
## 1182 MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old.
## 1183 MRI of lumbar spine without contrast to evaluate chronic back pain.
## 1184 MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.
## 1185 MRI Orbit/Face/Neck with MR Angiography of the Head - An infant with facial mass
## 1186 Left shoulder pain. Evaluate for rotator cuff tear.
## 1187 MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis.
## 1188 MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.
## 1189 MRI left knee without contrast.
## 1190 MRI left knee.
## 1191 MRI right knee without gadolinium
## 1192 Pain and swelling in the right foot, peroneal tendon tear.
## 1193 MRI Head W&WO Contrast.
## 1194 A 49-year-old female with ankle pain times one month, without a specific injury.
## 1195 A 53-year-old female with left knee pain being evaluated for ACL tear.
## 1196 MRI head without contrast.
## 1197 MRI left knee without contrast.
## 1198 Pain and swelling in the right foot.
## 1199 MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.
## 1200 MRI report Cervical Spine (Chiropractic Specific)
## 1201 MRI C-spine: C4-5 Transverse Myelitis.
## 1202 MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.
## 1203 MRI Elbow - A middle-aged female complaining of elbow pain.
## 1204 Left third digit numbness and wrist pain.
## 1205 MRI cervical spine.
## 1206 MRI Brain: Subacute right thalamic infarct.
## 1207 MRI Cervical Spine without contrast.
## 1208 MRI Brain & T-spine - Demyelinating disease.
## 1209 MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.
## 1210 Bilateral breast MRI with & without IV contrast.
## 1211 MRI Brain and Brainstem - Falling (Multiple System Atrophy)
## 1212 MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.
## 1213 MRI Brain: Thrombus in torcula of venous sinuses.
## 1214 MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.
## 1215 MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.
## 1216 Right pontine pyramidal tract infarct.
## 1217 A middle-aged female with memory loss.
## 1218 A middle-aged male with increasing memory loss and history of Lyme disease.
## 1219 MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH)
## 1220 MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.
## 1221 MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.
## 1222 MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis.
## 1223 MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.
## 1224 MRI Brain, Carbon Monoxide poisoning.
## 1225 MRI Brain - Olfactory groove meningioma.
## 1226 MRI right ankle.
## 1227 Cerebral Angiogram - moyamoya disease.
## 1228 MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual.
## 1229 Patient with right ankle pain.
## 1230 Lexiscan myoview stress study. Chest discomfort. Normal stress/rest cardiac perfusion with no indication of ischemia. Normal LV function and low likelihood of significant epicardial coronary narrowing.
## 1231 Left lower extremity venous Doppler ultrasound
## 1232 Lexiscan Nuclear Myocardial Perfusion Scan. Chest pain. Patient unable to walk on a treadmill. Nondiagnostic Lexiscan. Normal nuclear myocardial perfusion scan.
## 1233 Myoview nuclear stress study. Angina, coronary artery disease. Large fixed defect, inferior and apical wall, related to old myocardial infarction.
## 1234 Magnified Airway Study - An 11-month-old female with episodes of difficulty in breathing, cough.
## 1235 Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain.
## 1236 Resting Myoview and adenosine Myoview SPECT
## 1237 Lower Extremity Arterial Doppler
## 1238 Diagnostic laparoscopy and drainage of cyst.
## 1239 Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.
## 1240 Nuclear Medicine Therapy Intraarterial Particulate Administration
## 1241 Laparoscopic cholecystectomy with cholangiogram. Acute gangrenous cholecystitis with cholelithiasis. The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.
## 1242 Sellar HCT - Pituitary mass
## 1243 Intensity-modulated radiation therapy simulation note. The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.
## 1244 Right upper quadrant pain. Nuclear medicine hepatobiliary scan. Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.
## 1245 Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.
## 1246 Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings)
## 1247 Hyperfractionation. This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.
## 1248 Sample Radiology report of knee (growth arrest lines).
## 1249 HDR Brachytherapy
## 1250 Mammogram, bilateral full-field digital mammography FFDM (patient with positive history of breast cancer).
## 1251 Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain.
## 1252 HCT for memory loss and for calcification of basal ganglia (globus pallidi).
## 1253 Exercise myocardial perfusion study. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%
## 1254 Endovascular Brachytherapy (EBT)
## 1255 Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands. The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.
## 1256 The patient is status post C3-C4 anterior cervical discectomy and fusion.
## 1257 The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey.
## 1258 A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities. Abnormal electrodiagnostic study.
## 1259 Common Excretory Urogram - IVP template
## 1260 A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.
## 1261 Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck pain and left low back pain.
## 1262 EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy,
## 1263 Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.
## 1264 A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.
## 1265 This is a 95.5-hour continuous video EEG monitoring study.
## 1266 Echocardiographic Examination Report. Angina and coronary artery disease. Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension.
## 1267 Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.
## 1268 History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.
## 1269 Echocardiographic examination. Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.
## 1270 The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.
## 1271 Echocardiogram was performed including 2-D and M-mode imaging.
## 1272 Possible cerebrovascular accident. The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.
## 1273 Echocardiogram with color flow and conventional Doppler interrogation.
## 1274 Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm
## 1275 Duplex ultrasound of legs
## 1276 Dobutamine Stress Echocardiogram. Chest discomfort, evaluation for coronary artery disease. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate. Negative EKG criteria for ischemia.
## 1277 Diagnostic cerebral angiogram and transcatheter infusion of papaverine
## 1278 Diagnostic Mammogram and ultrasound of the breast.
## 1279 CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.
## 1280 CT of abdomen with and without contrast. CT-guided needle placement biopsy.
## 1281 CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.
## 1282 Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration.
## 1283 Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine. Nondiagnostic dobutamine stress test. Normal nuclear myocardial perfusion scan.
## 1284 Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.
## 1285 Noncontrast CT abdomen and pelvis per renal stone protocol.
## 1286 CT Scan of brain without contrast.
## 1287 CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.
## 1288 CT of chest with contrast. Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.
## 1289 CT of the facial bones without contrast due to hit in nose.
## 1290 CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.
## 1291 CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.
## 1292 CT REPORT - Soft Tissue Neck
## 1293 CT REPORT - Soft Tissue Neck
## 1294 This is a middle-aged female with two month history of low back pain and leg pain.
## 1295 Common CT Neck template.
## 1296 Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.
## 1297 CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.
## 1298 The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan. The patient's subdural effusions are still noticeable, but they are improving.
## 1299 Left arm and hand numbness. CT head without contrast. Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.
## 1300 Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.
## 1301 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.
## 1302 Common CT Head template.
## 1303 Common CT Facial template.
## 1304 Noncontrast CT abdomen and pelvis per renal stone protocol.
## 1305 CT cervical spine for trauma. CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization.
## 1306 Noncontrast CT head due to seizure disorder.
## 1307 Axial images through the cervical spine with coronal and sagittal reconstructions.
## 1308 CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration.
## 1309 Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained.
## 1310 Common CT Chest template
## 1311 Common CT C-Spine template
## 1312 Stroke in distribution of recurrent artery of Huebner (left)
## 1313 A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast.
## 1314 CT of Brain - Subacute SDH.
## 1315 CT chest with contrast.
## 1316 CT Brain: Subarachnoid hemorrhage.
## 1317 CT Brain: Midbrain hemangioma
## 1318 HCT: Subdural hemorrhage.
## 1319 CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).
## 1320 CT Brain: Suprasellar aneurysm, pre and post bleed.
## 1321 Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast.
## 1322 Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.
## 1323 Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.
## 1324 Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
## 1325 CT abdomen without contrast and pelvis without contrast, reconstruction.
## 1326 Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
## 1327 Right-sided abdominal pain with nausea and fever. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.
## 1328 CT brain (post craniectomy) - RMCA stroke and SBE.
## 1329 Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.
## 1330 Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.
## 1331 CT abdomen and pelvis without contrast, stone protocol, reconstruction.
## 1332 CT scan of the abdomen and pelvis without and with intravenous contrast.
## 1333 Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast.
## 1334 CT of the abdomen and pelvis without contrast.
## 1335 CT Abdomen and Pelvis with contrast
## 1336 A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.
## 1337 CT Abdomen & Pelvis W&WO Contrast
## 1338 CCTA with Cardiac Function/Calcium Scoring
## 1339 Coronary Artery CTA with Calcium Scoring and Cardiac Function
## 1340 Conformal simulation with coplanar beams. This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.
## 1341 A 51-year-old male with chest pain and history of coronary artery disease.
## 1342 CCTA with cardiac function and calcium scoring.
## 1343 Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.
## 1344 Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms.
## 1345 Chest CT - Thymoma and history of ocular myasthenia gravis.
## 1346 Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery.
## 1347 Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.
## 1348 Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection.
## 1349 Concomitant chemoradiotherapy for curative intent patients.
## 1350 Patient with chest pains, CAD, and cardiomyopathy.
## 1351 Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.
## 1352 Cardiolite treadmill exercise stress test. The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.
## 1353 Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).
## 1354 Bilateral carotid ultrasound.
## 1355 Carotid Ultrasonic & Color Flow Imaging
## 1356 Bilateral Mammogram, (abnormal) additional views requested
## 1357 Carotid artery angiograms.
## 1358 Ultrasound BPP - Advanced maternal age and hypertension.
## 1359 Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.
## 1360 BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.
## 1361 Brain CT and MRI - suprasellar mass (pituitary adenoma)
## 1362 Barium enema - history of encopresis and constipation.
## 1363 Arterial imaging of bilateral lower extremities.
## 1364 MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.
## 1365 Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.
## 1366 CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.
## 1367 Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan.
## 1368 MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).
## 1369 MRI - Arteriovenous malformation with hemorrhage.
## 1370 MRI - Right temporal lobe astrocytoma.
## 1371 2-D Echocardiogram
## 1372 3-Dimensional Simulation. This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.
## 1373 2-D Echocardiogram
## 1374 Echocardiogram and Doppler
## 1375 2-D M-Mode. Doppler.
## 1376 Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.
## 1377 Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.
## 1378 Austin & Youngswick bunionectomy with Biopro implant. Screw fixation, left foot.
## 1379 Consultation for wrist pain.
## 1380 Excision of dorsal wrist ganglion. Made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.
## 1381 Unilateral transpedicular T11 vertebroplasty.
## 1382 Trigger thumb release. Right trigger thumb. The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release).
## 1383 Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa. Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.
## 1384 Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve.
## 1385 Trigger finger release. A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.
## 1386 Decompression of the ulnar nerve, left elbow. Left cubital tunnel syndrome and ulnar nerve entrapment.
## 1387 Total knee replacement. A midline incision was made, centered over the patella. Dissection was sharply carried down through the subcutaneous tissues. A median parapatellar arthrotomy was performed.
## 1388 Right total knee arthroplasty - Osteoarthritis, right knee.
## 1389 Total left knee replacement. Degenerative arthritis of the left knee. Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.
## 1390 Trigger thumb release. A transverse incision was made over the MPJ crease of the thumb. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.
## 1391 Right knee total arthroplasty. Degenerative osteoarthritis, right knee.
## 1392 Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy.
## 1393 Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.
## 1394 Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues.
## 1395 Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella. All components were cemented with Cobalt G.
## 1396 Right hip osteoarthritis. Total hip replacement on the right side.
## 1397 NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.
## 1398 Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.
## 1399 Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty.
## 1400 History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle. Insertion of tissue expander to the medial and lateral wound.
## 1401 Pain. Three views of the right ankle. Three views of the right ankle are obtained.
## 1402 Right foot trauma. Three views of the right foot. Three views of the right foot were obtained.
## 1403 Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.
## 1404 Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.
## 1405 Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot.
## 1406 Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.
## 1407 Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.
## 1408 Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.
## 1409 Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.
## 1410 Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.
## 1411 Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.
## 1412 Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome.
## 1413 Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.
## 1414 Superior labrum anterior and posterior lesion repair.
## 1415 Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.
## 1416 Frontal and lateral views of the hip and pelvis.
## 1417 Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy.
## 1418 Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.
## 1419 Consultation for right shoulder pain.
## 1420 Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.
## 1421 Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot.
## 1422 Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder.
## 1423 Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease.
## 1424 Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.
## 1425 Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.
## 1426 Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.
## 1427 The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.
## 1428 Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.
## 1429 A sample note on RICE Therapy
## 1430 Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.
## 1431 Closed reduction and pinning of the right ulna with placement of a long-arm cast.
## 1432 Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.
## 1433 Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
## 1434 External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.
## 1435 Revision and in situ pinning of the right hip.
## 1436 Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.
## 1437 Open repair of right pectoralis major tendon. Right pectoralis major tendon rupture. On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.
## 1438 Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient would benefit from skilled physical therapy intervention.
## 1439 Specimen labeled "sesamoid bone left foot".
## 1440 Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor.
## 1441 The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.
## 1442 A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis.
## 1443 The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back.
## 1444 Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee.
## 1445 Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.
## 1446 Pain management sample progress note.
## 1447 Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.
## 1448 Pain management for post-laminectomy low back syndrome and radiculopathy.
## 1449 Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction.
## 1450 Orthopedic progress note for follow up of osteoarthritis, knees.
## 1451 OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis.
## 1452 Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.
## 1453 Patient with back and hip pain.
## 1454 Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.
## 1455 Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs
## 1456 Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.
## 1457 Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.
## 1458 Medical management, status post left total knee arthroplasty.
## 1459 Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.
## 1460 A 19-year-old right-handed male injured in a motor vehicle accident.
## 1461 Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius.
## 1462 The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.
## 1463 Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3.
## 1464 Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.
## 1465 Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.
## 1466 Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture. Closed reduction and screw fixation of right femoral neck fracture. Retrograde femoral nail using a striker T2 retrograde nail. Irrigation and debridement of knee and elbow abrasions.
## 1467 Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.
## 1468 Open reduction and internal fixation of left distal radius.
## 1469 Open reduction and internal fixation of left tibia.
## 1470 Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.
## 1471 Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.
## 1472 Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.
## 1473 Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.
## 1474 Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.
## 1475 Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint.
## 1476 Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.
## 1477 MRI L-Spine - Bilateral lower extremity numbness
## 1478 Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.
## 1479 Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.
## 1480 Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.
## 1481 Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.
## 1482 Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.
## 1483 Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.
## 1484 Initial evaulation - neck and back pain.
## 1485 MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.
## 1486 Patient with wrist pain and swelling, status post injury.
## 1487 MRI T-spine and CXR - Aortic Dissection.
## 1488 The thoracic spine was examined in the AP, lateral and swimmer's projections.
## 1489 Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder. Partial rotator cuff tear with impingement syndrome. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.
## 1490 Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.
## 1491 MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.
## 1492 MRI left shoulder.
## 1493 MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.
## 1494 A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.
## 1495 MRI of the Cervical, Thoracic, and Lumbar Spine
## 1496 MRI of lumbar spine without contrast to evaluate chronic back pain.
## 1497 MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.
## 1498 MRI right knee without gadolinium
## 1499 MRI left knee.
## 1500 A 32-year-old male with shoulder pain.
## 1501 A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.
## 1502 MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.
## 1503 Left shoulder pain. Evaluate for rotator cuff tear.
## 1504 MRI left knee without contrast.
## 1505 A 53-year-old female with left knee pain being evaluated for ACL tear.
## 1506 Pain and swelling in the right foot.
## 1507 MRI left knee without contrast.
## 1508 A 49-year-old female with ankle pain times one month, without a specific injury.
## 1509 Pain and swelling in the right foot, peroneal tendon tear.
## 1510 MRI C-spine: C4-5 Transverse Myelitis.
## 1511 MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.
## 1512 MRI Elbow - A middle-aged female complaining of elbow pain.
## 1513 MRI Cervical Spine without contrast.
## 1514 MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.
## 1515 MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.
## 1516 MRI cervical spine.
## 1517 MRI right ankle.
## 1518 Left third digit numbness and wrist pain.
## 1519 MRI report Cervical Spine (Chiropractic Specific)
## 1520 Patient with right ankle pain.
## 1521 MRI Brain & T-spine - Demyelinating disease.
## 1522 Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.
## 1523 Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee. Patellar chondroplasty. Lateral femoral chondroplasty. Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,
## 1524 Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.
## 1525 Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.
## 1526 Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
## 1527 Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.
## 1528 Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.
## 1529 Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.
## 1530 Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.
## 1531 Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain.
## 1532 Lumbar muscle strain and chronic back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.
## 1533 Microscopic lumbar discectomy, left L5-S1. Extruded herniated disc, left L5-S1. Left S1 radiculopathy (acute). Morbid obesity.
## 1534 New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.
## 1535 Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.\r\n
## 1536 Evaluation for right L4 selective nerve root block.
## 1537 Ligament reconstruction and tendon interposition arthroplasty of right wrist.
## 1538 Closed reduction and placement of long-arm cast.
## 1539 Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin. Repair of lateral meniscus using two fast fixed meniscal repair sutures. Partial medial meniscectomy. Partial chondroplasty of patella. Lateral retinacular release. Open medial plication as well of the right knee.
## 1540 Lateral release with lengthening of the ECRB tendon. Lateral epicondylitis.
## 1541 Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.
## 1542 History of right leg pain. Leg pain is no longer present.
## 1543 Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1.
## 1544 Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.
## 1545 A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture.
## 1546 Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP. Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.
## 1547 Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.
## 1548 Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.
## 1549 KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy.
## 1550 Left medial compartment osteoarthritis of the knee. Left unicompartmental knee replacement.
## 1551 The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time.
## 1552 Decreased ability to perform daily living activities secondary to right knee surgery.
## 1553 Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. Vertebroplasties at T7 and T9 with insertion of prosthetic device. Fracture of the T8 vertebra and T9 vertebra.
## 1554 Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.
## 1555 Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling.
## 1556 Left knee arthroscopy with lateral capsular release.
## 1557 Arthroscopic procedure of the knee.
## 1558 Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.
## 1559 Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.
## 1560 Evaluation for chronic pain program
## 1561 Revision right total knee arthroplasty. Right failed total knee arthroplasty.
## 1562 Left below-the-knee amputation. Dressing change, right foot.
## 1563 A 66-year-old female with knee osteoarthrosis who failed conservative management.
## 1564 Bilateral degenerative arthritis of the knees. Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.
## 1565 Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail. Left tibial shaft fracture status post gunshot wound.
## 1566 Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.
## 1567 Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized.
## 1568 A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.
## 1569 Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast.
## 1570 Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.
## 1571 Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing
## 1572 Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.
## 1573 Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.
## 1574 Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.
## 1575 Decreased ability to perform daily living activity secondary to recent right hip surgery.
## 1576 Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.
## 1577 Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus.
## 1578 Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.
## 1579 Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.
## 1580 Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture.
## 1581 Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.
## 1582 Hardware removal in the left elbow.
## 1583 New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room.
## 1584 Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.
## 1585 Hardware removal, right ulnar
## 1586 Left distal medial hamstring release.
## 1587 Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.
## 1588 Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.
## 1589 Consultation for left foot pain.
## 1590 Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.
## 1591 Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.
## 1592 Flexor carpi radialis and palmaris longus repair. Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.
## 1593 Consultation for FCR tendinitis
## 1594 Sample Radiology report of knee (growth arrest lines).
## 1595 Endoscopic carpal tunnel release. Left carpal tunnel syndrome.
## 1596 Left little finger extensor tendon laceration. Repair of left little extensor tendon.
## 1597 Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.
## 1598 Consultation for finger triggering and locking.
## 1599 Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.
## 1600 Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.
## 1601 Left elbow manipulation and hardware removal of left elbow.
## 1602 Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.
## 1603 Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.
## 1604 Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.
## 1605 A 47-year-old female with a posttraumatic AV in the right femoral head.
## 1606 Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs
## 1607 Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment.
## 1608 Trauma/ATV accident resulting in left open humerus fracture.
## 1609 Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
## 1610 Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.
## 1611 Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.
## 1612 Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.
## 1613 Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.
## 1614 Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.
## 1615 Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder. Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.
## 1616 Incision and drainage with extensive debridement, left shoulder. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component). Implantation of antibiotic beads, left shoulder.
## 1617 Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis. Carpal tunnel release and de Quervain's release. A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis.
## 1618 CT REPORT - Soft Tissue Neck
## 1619 Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.
## 1620 CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.
## 1621 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.
## 1622 This is a middle-aged female with two month history of low back pain and leg pain.
## 1623 CT REPORT - Soft Tissue Neck
## 1624 Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.
## 1625 Common CT C-Spine template
## 1626 Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained.
## 1627 CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.
## 1628 The patient has been suffering from intractable back and leg pain.
## 1629 Lateral and plantar condylectomy, fifth left metatarsal.
## 1630 Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.
## 1631 Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet.
## 1632 Axial images through the cervical spine with coronal and sagittal reconstructions.
## 1633 CT cervical spine for trauma. CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization.
## 1634 Trimalleolar ankle fracture and dislocation right ankle. A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well. Closed open reduction and internal fixation of right ankle.
## 1635 Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted.
## 1636 Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.
## 1637 Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.
## 1638 Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.
## 1639 Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe.
## 1640 Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.
## 1641 Carpal tunnel syndrome. Endoscopic carpal tunnel release. After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.
## 1642 Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.
## 1643 Carpal tunnel syndrome. Open carpal tunnel release. A longitudinal incision was made in line with the 4th ray. The dissection was carried down to the superficial aponeurosis, which was cut. The distal edge of the transverse carpal ligament was identified with a hemostat.
## 1644 Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.
## 1645 Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity.
## 1646 Right carpal tunnel release. Right carpal tunnel syndrome. This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.
## 1647 Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.
## 1648 Right carpal tunnel syndrome. Right carpal tunnel release.
## 1649 Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.
## 1650 Bilateral open carpal tunnel release.
## 1651 Left endoscopic carpal tunnel release and endotracheal fasciotomy.
## 1652 Right open carpal tunnel release and cortisone injection, left carpal tunnel.
## 1653 Right carpal tunnel release.
## 1654 Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis.
## 1655 Endoscopic release of left transverse carpal ligament.
## 1656 Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.
## 1657 Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.
## 1658 Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.
## 1659 Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.
## 1660 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.
## 1661 Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger.
## 1662 Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.
## 1663 Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal.\r\n
## 1664 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes.
## 1665 Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.
## 1666 Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.
## 1667 A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The pain is located laterally as well as anteriorly into the groin.
## 1668 Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.
## 1669 Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal. Excision of nerve lesion with implantation of the muscle belly of the left second interspace. Excision of nerve lesion in the left third interspace.\r\n
## 1670 Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation.
## 1671 Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.
## 1672 Ruptured distal biceps tendon, right elbow. Repair of distal biceps tendon, right elbow.
## 1673 Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.
## 1674 Diagnostic arthroscopy exam under anesthesia, left shoulder. Debridement of chondral injury, left shoulder. Debridement, superior glenoid, left shoulder. Arthrotomy. Bankart lesion repair. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).
## 1675 Austin bunionectomy with internal screw fixation, first metatarsal, left foot.
## 1676 Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure.
## 1677 Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.
## 1678 Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint. Weil osteotomy with internal screw fixation, first right metatarsal. Arthroplasty, second right PIP joint.
## 1679 Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.
## 1680 Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well. Chondromalacia of medial femoral condyle. Medial meniscal tear, left knee.
## 1681 Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.
## 1682 Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.
## 1683 Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.
## 1684 Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.
## 1685 Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.
## 1686 Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.
## 1687 Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.
## 1688 Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.
## 1689 Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.
## 1690 Rotator cuff tear, right shoulder. Superior labrum anterior and posterior lesion (peel-back), right shoulder. Arthroscopy with arthroscopic SLAP lesion. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.
## 1691 Femoroacetabular impingement. Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.
## 1692 Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.
## 1693 Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.
## 1694 Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain.
## 1695 Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.
## 1696 Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.
## 1697 Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.
## 1698 Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.
## 1699 Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.
## 1700 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.
## 1701 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.
## 1702 C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.
## 1703 C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.
## 1704 Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.
## 1705 Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.
## 1706 Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.
## 1707 Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation
## 1708 Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.
## 1709 Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.
## 1710 Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).
## 1711 Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.
## 1712 Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.
## 1713 Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5.
## 1714 Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.
## 1715 C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.
## 1716 Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.
## 1717 Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.
## 1718 Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant. Disc herniation with right arm radiculopathy.
## 1719 Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.\r\n7. Microscopic dissection.
## 1720 Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.
## 1721 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.
## 1722 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.
## 1723 Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.
## 1724 History and Physical for right ankle sprain
## 1725 Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.
## 1726 Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.
## 1727 The patient was running and twisted her right ankle - right ankle sprain.
## 1728 Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.
## 1729 Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.
## 1730 Right Achilles tendon rupture.
## 1731 Bilateral open Achilles lengthening with placement of short leg walking cast.
## medical_specialty
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## 1500 Orthopedic
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## 1600 Orthopedic
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## 1727 Orthopedic
## 1728 Orthopedic
## 1729 Orthopedic
## 1730 Orthopedic
## 1731 Orthopedic
## sample_name
## 1 Youngswick Bunionectomy
## 2 YAG Laser Capsulotomy - 1
## 3 Youngswick Osteotomy
## 4 Wound Debridement
## 5 YAG Laser Capsulotomy
## 6 Wound Closure & Debridement - Hydrocephalus
## 7 Wrist Ganglion Excision
## 8 VP Shunt Placement
## 9 Vitrectomy - Local Anesthesia
## 10 Vitrectomy - General Anesthesia
## 11 Vitrectomy Opening
## 12 Vitrectomy - 2
## 13 Vertebroplasty
## 14 VVIR Permanent Pacemaker Insertion
## 15 Vitrectomy - 3
## 16 Vitrectomy - 1
## 17 Ventriculostomy Placement
## 18 Vein Stripping
## 19 Vasectomy - 4
## 20 Vasectomy - 3
## 21 Ventriculostomy
## 22 Ventricular Drain Catheter Insertion
## 23 Vitrectomy
## 24 Vasectomy - 2
## 25 Vasectomy - 1
## 26 Vasectomy
## 27 Vaginal Hysterectomy - Laparoscopic-Assisted
## 28 Vaginal Hysterectomy
## 29 Vaginal Delivery - Vacuum-Assisted
## 30 Umbilical Hernia Repair
## 31 Upper Endoscopy
## 32 Uterine Suction Curettage
## 33 Urgent Cardiac Cath
## 34 Uvulopalatopharyngoplasty & Tonsillectomy
## 35 Umbilical Hernia Repair - 1
## 36 Vacuum D&C
## 37 Ulnar Nerve Transposition
## 38 Upper Endoscopy - Foreign Body Removal
## 39 Tympanostomy & Myringotomy Tube Placement
## 40 Tympanostomy
## 41 TURBT - 1
## 42 Ulnar Nerve Decompression
## 43 TURP
## 44 Tube Shunt - Ahmed Valve Implant
## 45 Tubal Sterilization & Coagulation
## 46 Ulnar Nerve Transposition & Olecranon Bursa Excision
## 47 Tympanomastoidectomy
## 48 Tubal Ligation - Laparoscopic
## 49 TURBT
## 50 True Cut Needle Biopsy - Breast
## 51 Tun-L Catheter Placement
## 52 Tubal Ligation - Postpartum
## 53 Tubal Fulguration - Laparoscopic
## 54 Tubal Ligation
## 55 Ttriple-Lumen Central Line
## 56 Trigger Thumb Release - 1
## 57 Transpedicular Decompression
## 58 Triple Lumen Catheter Insertion
## 59 Triple Lumen Catheter Insertion - 1
## 60 Trigger Finger Release
## 61 Trigger Thumb Release
## 62 Transesophageal Echocardiography Probe
## 63 Transurethral Resection Of Bladder Tumor
## 64 Tracheotomy - 1
## 65 Trabeculectomy
## 66 Tracheostomy & Thyroid Isthmusectomy
## 67 Tracheostomy Change
## 68 Tracheostomy
## 69 Total Thyroidectomy
## 70 Total Thyroid Lumpectomy
## 71 Total Knee Replacement - 1
## 72 Trabeculectomy & Tenonectomy
## 73 Tracheostomy & SCOOP Procedure
## 74 Total Knee Arthroplasty - Right
## 75 Total Knee Replacement
## 76 Total Knee Replacement - NexGen
## 77 Total Knee Arthoplasty - Right - 1
## 78 Total Hip Arthroplasty - Revision
## 79 Total Knee Arthroplasty
## 80 Total Hip Arthroplasty
## 81 Total Hip Replacement - 1
## 82 Total Hip Replacement
## 83 Total Abdominal Hysterectomy - 3
## 84 Toronto Porcine Valve Insertion
## 85 Total Abdominal Hysterectomy - 1
## 86 Total Abdominal Hysterectomy
## 87 Total Abdominal Hysterectomy - 2
## 88 Tonsillectomy & Adenoidectomy - 5
## 89 Tonsillectomy & Adenoidectomy - 4
## 90 Tonsillectomy & Adenoidectomy - 3
## 91 Tonsillectomy & Adenoidectomy - 1
## 92 Tonsillectomy and Septoplasty
## 93 Tonsillectomy - 1
## 94 Tonsillectomy
## 95 Tonsillectomy & Adenoidectomy
## 96 Tonsillectomy & Adenoidectomy - 2
## 97 Thyroidectomy - 1
## 98 Thromboendarterectomy
## 99 Tongue Lesion Biopsy
## 100 TLIF
## 101 Thyroidectomy
## 102 Tissue Expander Insertion
## 103 Thrombectomy AV Shunt
## 104 Thoracotomy & Esophageal Exploration
## 105 Thoracotomy & Bronchoscopy
## 106 Thoracoabdominal Aneurysm
## 107 Thoracotomy & Pleurectomy
## 108 Thoracoscopy & Thoracotomy - Mesothelioma
## 109 Thrombectomy
## 110 Thoracoscopy/Thoracotomy
## 111 Thoracic Discectomy
## 112 Temporal Artery Biopsy
## 113 Thoracentesis - 1
## 114 Tesio Hemodialysis Catheter Insertion
## 115 Temporal Artery Biopsy - 1
## 116 Teeth Extraction & I&D - 2
## 117 Tessio Catheter Insertion
## 118 Thoracentesis
## 119 Teeth Extraction & I&D - 1
## 120 Tenosynovectomy & Cortisone Injection
## 121 Tarsectomy
## 122 Teeth Extraction & I&D
## 123 Teeth Extraction
## 124 Teeth (full-mouth) Extraction
## 125 TAH & Salpingo-oophorectomy - 1
## 126 TAH & Salpingooophorectomy
## 127 TAH & Salpingo-oophorectomy & Lysis of Adhesions
## 128 Synovectomy - Partial
## 129 Tailor Bunionectomy with Screw Fixation
## 130 TAH & Salpingo-oophorectomy
## 131 SynchroMed Pump Placement
## 132 TAH & BSO
## 133 Suction, Dilation, & Curettage
## 134 Symes Amputation - Hallux
## 135 Surgical Closure of Gastrostomy
## 136 Subxiphoid Pericardial Window - 1
## 137 Surgical Removal of Teeth
## 138 Subxiphoid Pericardiotomy
## 139 Superior Labrum Lesions Repair
## 140 Suction, Dilation, & Curettage - 1
## 141 Subcutaneous Transposition of Ulnar Nerve
## 142 Suboccipital Craniectomy
## 143 Subxiphoid Pericardial Window
## 144 Subperiosteal Abscess Debridement
## 145 Subclavian Central Venous Catheter Insertion
## 146 Stamm Gastrostomy Tube Placement
## 147 Stenting
## 148 Spontaneous Vaginal Delivery - 1
## 149 Spontaneous Vaginal Delivery
## 150 Stab Wound Closure
## 151 Stapedectomy - Argon Lasor Assisted
## 152 Spinal Manipulation
## 153 Styloidectomy
## 154 Spinal Fusion & Instrumentation
## 155 Spine Fusion
## 156 Spermatocelectomy
## 157 Spinal fluid evaluation
## 158 Skin Graft
## 159 Sling (SPARC Suburethral)
## 160 Skull Base Reconstruction
## 161 Skin Biopsy
## 162 Sinus Surgery - Endoscopic
## 163 Sinus Fractures Repairs
## 164 Spermatocelectomy, Epididymectomy, & Vasectomy
## 165 Shunt Revision - 3
## 166 Shockwave Lithotripsy
## 167 Shunt Revision - 2
## 168 Shoulder Hemi-resurfacing
## 169 Shunt Revision - 1
## 170 Shunt Revision
## 171 Sigmoidoscopy - 1
## 172 Shiley Tracheostomy Tube Insertion
## 173 Sebaceous Cyst Excision
## 174 Septorhinoplasty
## 175 Scrotal Exploration
## 176 Scleral Buckle Opening - Local Anesthesia
## 177 Selective Coronary Angiography & Angioplasty
## 178 Septoplasty
## 179 Scott Cannula
## 180 Septoplasty & Turbinectomy
## 181 Septal Defect Repair
## 182 Sebaceous Cyst Removal
## 183 Scalp Mole Skin Biopsy
## 184 Scleral Buckle Opening
## 185 Saphenous Vein - Ligation & Stripping
## 186 Scarf Bunionectomy
## 187 Scleral Buckle Opening - General Anesthesia
## 188 Salpingectomy & Cervical Dilatation
## 189 Sacral Decubitus Debridement
## 190 Ruptured Globe Repair - Sclera and Limbus
## 191 Salpingooophorectomy - Laparoscopic
## 192 Salvage Cystectomy
## 193 Ruptured Globe Repair - Posterior Sclera
## 194 Rhytidectomy & Blepharoplasty
## 195 Right Shoulder Hemiarthroplasty
## 196 Rotator Cuff Repair
## 197 Ruptured Globe Repair - Cornea
## 198 Retrograde Pyelogram & Cystourethroscopy
## 199 Revision Rhinoplasty.
## 200 Rhinectomy & Nasal Endoscopy
## 201 Repair of Canthal & Lid Defect
## 202 Repeat C-section
## 203 Renal Transplant - Cadaveric
## 204 Removal of Venous Port
## 205 Resection of Tumor of Scalp
## 206 Radiofrequency Thermocoagulation - 2
## 207 Rhinoplasty
## 208 Release of A1 Pulley - 1
## 209 Rectus Recession
## 210 Release of A1 Pulley
## 211 Radioactive Plaque - Removal
## 212 Rectovaginal Fistula Closure
## 213 Radiofrequency Thermocoagulation
## 214 Radiofrequency Thermocoagulation - 1
## 215 Radiofrequency Ablation
## 216 Radical Mastectomy - 1
## 217 Radical Mastectomy
## 218 Pyeloureteroscopy
## 219 Radical Vulvectomy
## 220 Punch Biopsy - 2
## 221 Pulmonary Valve Stenosis
## 222 Radical Hysterectomy
## 223 Pyeloplasty - Robotic
## 224 Punch Biopsy - 1
## 225 Radioactive Plaque - Insertion
## 226 Prostatectomy - Robotic Radical Retropubic
## 227 Prostatectomy
## 228 Prostatectomy - Nerve Sparing
## 229 Prostatectomy - Radical Retropubic
## 230 Pulmonary Atresia
## 231 Port-A-Cath Insertion - 4
## 232 Pterional Craniotomy
## 233 Port-A-Cath Insertion - 3
## 234 Port-A-Cath Insertion - 5
## 235 Port-A-Cath Insertion - 1
## 236 Postop Transanal Excision
## 237 Post Hemithyroidectomy
## 238 Port-A-Cath Insertion - 2
## 239 Port Insertion
## 240 Port-A-Cath Insertion
## 241 Pituitary Tumor Resection
## 242 PMT Halo Crown & Vest
## 243 Pleurocentesis
## 244 Pinning - Ulna
## 245 Plantar Fasciotomy
## 246 Pleurodesis
## 247 Pituitary Adenomectomy
## 248 Plantar Fasciitis
## 249 Pilon Fracture External Fixation
## 250 Pilonidal Cyst Excision
## 251 Pinning - Hip
## 252 Pigtail Catheter Insertion
## 253 Phenol Neurolysis & Botulinum Toxin Injection - 3
## 254 Phenol Neurolysis & Botulinum Toxin Injection - 1
## 255 Phacoemulsification of Cataract
## 256 Phenol Neurolysis & Botulinum Toxin Injection - 2
## 257 Phacoemulsification Of Cataract - 2
## 258 PICC line insertion
## 259 Phacoemulsification & Lens Implantation - 7
## 260 Phacoemulsification of Cataract - 1
## 261 Phacoemulsification & Lens Implantation - 6
## 262 Phalanx Amputation
## 263 Phacoemulsification & Lens Implantation - 5
## 264 Phacoemulsification & Lens Implantation - 4
## 265 Phacoemulsification & Lens Implantation - 3
## 266 Phacoemulsification & Cataract Extraction - 4
## 267 Phacoemulsification & Lens Implantation - 2
## 268 Phacoemulsification & Cataract Extraction - 3
## 269 Phacoemulsification & Cataract Extraction - 5
## 270 Phacoemulsification & Lens Implantation - 1
## 271 Phacoemulsification & Cataract Extraction - 2
## 272 Phacoemulsification & Cataract Extraction - 1
## 273 Phacoemulsification & Lens Implantation
## 274 Phacoemulsification & Cataract Extraction
## 275 Perlane & Restylane Injection
## 276 Penile Prosthesis Replacement
## 277 Peritoneal Dialysis Catheter Insertion
## 278 Permacath Placement
## 279 Phacoemulsification
## 280 Phacoemulsification - Kelman
## 281 Penile Skin Bridges Excision
## 282 Parotidectomy
## 283 Pelvic Laparotomy
## 284 PEG Tube
## 285 Pars Plana Vitrectomy & Lensectomy
## 286 Pectoralis Tendon Repair
## 287 Patent Ductus Arteriosus Ligation
## 288 Pacemaker Lead Placement & Rrevision.
## 289 Patent Ductus Arteriosus
## 290 Patellar Tendon & Retinaculum Repair
## 291 Parathyroid Adenoma Excision
## 292 Paracentesis
## 293 Paracentesis - Ultrasound-Guided
## 294 Paraphimosis
## 295 Pacemaker - DDDR
## 296 Pacemaker Insertion
## 297 Pacemaker Interrogation
## 298 Pacemaker (Dual Chamber) - 1
## 299 Pacemaker (Single Chamber)
## 300 Pacemaker (Dual Chamber)
## 301 Pacemaker (Single Chamber) - 1
## 302 Osteotomy & Bunionectomy - 1
## 303 ORIF of Left Distal Radius
## 304 OssaTron Extracorporeal Shockwave Therapy
## 305 ORIF Wrist - Acumed Locking Plate
## 306 Osteosynthesis
## 307 ORIF & Closed Reduction
## 308 Osteotomy & Bunionectomy
## 309 ORIF Mandibular Fracture & Dental Implant Removal
## 310 ORIF, Closed Reduction, Screw Fixation, Etc.
## 311 ORIF & Cervical Fusion
## 312 ORIF - Fifth Metatarsal
## 313 ORIF - Malleolus
## 314 ORIF - Mandible Fracture
## 315 ORIF - Left Tibia
## 316 ORIF - Talus
## 317 Orchiopexy & Herniorrhaphy
## 318 ORIF - 1
## 319 Orchiopexy - Bilateral
## 320 ORIF - 2
## 321 ORIF - 3
## 322 Orchiopexy & Hernia Repair - 1
## 323 Orchiopexy & Hernia Repair
## 324 Orchiopexy & Herniorrhaphy - 1
## 325 Odontogenic Abscess I&D
## 326 Orchiectomy & Testis Fixation
## 327 Ommaya reservoir
## 328 Orchiopexy
## 329 Orchiectomy
## 330 Olecranon Bursa - Excision
## 331 Open Plantar Fasciotomy
## 332 Open Cholecystectomy
## 333 Nissen Fundoplication
## 334 Nipple Reconstruction
## 335 Nephrectomy - Radical
## 336 Nephrectomy - Transplant
## 337 Neuroplasty
## 338 Nerve & Tendon Repair - Finger
## 339 Nephrectomy - Partial (Laparoscopic )
## 340 Nephrectomy - Radical (Laparoscopic)
## 341 Neuroma Excision
## 342 Needle-Localized Excisional Biopsy - Breast
## 343 Neuromodulator
## 344 Needle-Localized Excisional Biopsy - Breast - 1
## 345 Nephrectomy - Partial
## 346 Nephrectomy
## 347 Neck Mass Biopsy
## 348 Nasal Septoplasty & Tonsillectomy
## 349 Nasolabial Fold Elevation
## 350 Neck Dissection
## 351 Needle Localized Excision - Breast Neoplasm
## 352 Nasal Septal Reconstruction
## 353 Nasolacrimal Probing
## 354 Myringotomy/Tube Insertion - 2
## 355 Nasal Septoplasty
## 356 Myringotomy/Tube Insertion - 1
## 357 Myringotomy/Tube Insertion - 3
## 358 Multiple Stent Placements
## 359 Myringotomy/Tube Insertion
## 360 Mohs Micrographic Surgery - 1
## 361 Mitral Valve Repair & Annuloplasty
## 362 Mohs Micrographic Surgery - 2
## 363 Mumford Procedure & Acromioplasty
## 364 Midface Lift & Blepharoplasty
## 365 Middle Ear Exploration
## 366 Mini Laparotomy & Radical Retropubic Prostatectomy
## 367 Mesothelioma - Port-A-Cath Insertion
## 368 MediPort Placement
## 369 Mesothelioma - Thoracotomy & Lobectomy
## 370 Microsuspension Direct Laryngoscopy & Biopsy
## 371 Metastatic Lymphadenopathy & Thyroid Tissue Removal
## 372 Meniscoplasty & Chondroplasty
## 373 Mesothelioma - Pleural Biopsy
## 374 Metastasectomy & Bronchoscopy
## 375 Mediastinal Mass Resection
## 376 Mediastinal Exploration & Right Atrium Repair
## 377 Mediastinal Exploration
## 378 Medial Branch Rhizotomy
## 379 Mass Excision - Foot
## 380 Meatotomy Template
## 381 Mandible Fractures Closed Reduction
## 382 Mammoplasty - 1
## 383 Meatoplasty Template
## 384 McBride Bunionectomy & Wedge Osteotomy
## 385 Mammoplasty - 3
## 386 Mammoplasty - 2
## 387 Mammoplasty - 4
## 388 Lysis of Pelvic Adhesions
## 389 Lumpectomy & Lymph Node Biopsy
## 390 Lymph Node Excisional Biopsy
## 391 Lumbar Discogram
## 392 Lumbar Laminotomy & Discectomy
## 393 Lumbar Puncture
## 394 Lumbar Re-exploration
## 395 Lumbar Puncture - 2
## 396 Lumbar Laminectomy & Discectomy
## 397 Lumbar Puncture - 1
## 398 Lumbar Laminectomy
## 399 Lumbar Discectomy - Microscopic
## 400 Low-Transverse C-Section & BTL - 1
## 401 Low-Transverse C-Section - 5
## 402 Low-Transverse C-Section - 8
## 403 Low-Transverse C-Section - 4
## 404 Low-Transverse C-Section - 3
## 405 Low-Transverse C-Section & BTL
## 406 Low-Transverse C-Section - 7
## 407 Low-Transverse C-Section - 9
## 408 Low-Transverse C-Section - 6
## 409 Low-Transverse C-Section - 2
## 410 Low-Transverse C-Section - 1
## 411 Low-Transverse C-Section - 10
## 412 Low-Transverse C-Section
## 413 Lobectomy - VATS
## 414 Lobectomy & Lymphadenectomy
## 415 Low -Segment C-Section
## 416 Lobectomy & Lymph Node Dissection
## 417 Lobectomy - Left Lower
## 418 Liposuction
## 419 Long-Arm Cast
## 420 Lipoma Excision - 1
## 421 Lipectomy - Breast
## 422 Lipoma Excision
## 423 Liver Biopsy
## 424 Lipectomy - Abdomen/Thighs
## 425 Ligament Reconstruction & Meniscus Repair
## 426 Ligament Reconstruction & Tendon Interposition Arthroplasty
## 427 Lid Laceration Repair
## 428 Laryngoscopy & Vocal Cord Biopsy
## 429 Lateral Epicondylitis Release
## 430 Leaking ET tube
## 431 Laser Vaporization of Prostate
## 432 Laryngoscopy
## 433 Left Orchiectomy & Right Orchidopexy
## 434 Laser of Vulva
## 435 LEEP
## 436 Laryngectomy & Thyroid Lobectomy
## 437 Laparotomy & Salpingectomy
## 438 Laparoscopy & Sigmoidoscopy
## 439 Laparoscopy, Laparotomy, & Cholecystectomy
## 440 Laparotomy & Myomectomy
## 441 Laparoscopy - 3
## 442 Laparoscopy - 4
## 443 Laparoscopic Supracervical Hysterectomy.
## 444 Laparoscopy & Laparoscopic Appendectomy
## 445 Laparoscopy - 1
## 446 Laparoscopy
## 447 Laparoscopy - Drainage of Cyst
## 448 Laparoscopic Orchiopexy
## 449 Laparoscopy & Salpingo-oophorectomy
## 450 Laparoscopic Hysterectomy
## 451 Laparoscopy - 2
## 452 Laparoscopic Pyeloplasty
## 453 Laparoscopic Gastric Bypass
## 454 Laparoscopic Cryoablation
## 455 Laparoscopic Cholecystectomy & Liver Cyst Excision
## 456 Laparoscopic Gastric Bypass - 1
## 457 Laparoscopic Cholecystectomy & Appendectomy
## 458 Laparoscopic Cholecystectomy - 9
## 459 Laparoscopic Cholecystectomy & Cholangiogram - 1
## 460 Laparoscopic Cholecystectomy & Cholangiogram
## 461 Laparoscopic Cholecystectomy - 7
## 462 Laparoscopic Cholecystectomy - 8
## 463 Laparoscopic Cholecystectomy - 6
## 464 Laparoscopic Cholecystectomy - 10
## 465 Laparoscopic Cholecystectomy
## 466 Laparoscopic Cholecystectomy - 5
## 467 Laparoscopic Cholecystectomy - 4
## 468 Laparoscopic Cholecystectomy - 3
## 469 Laparoscopic Cholecystectomy - 2
## 470 Laparoscopic Cholecystectomy - 1
## 471 Laparoscopic Appendectomy - 2
## 472 Laparoscopic Ablation of Eendometrial Implants
## 473 Laparoscopic Appendectomy - 5
## 474 Laparoscopic Adrenalectomy
## 475 Laminotomy, Facetectomy & Foraminotomy
## 476 Laparoscopic Appendectomy - 1
## 477 Laparoscopic Appendectomy
## 478 Laminectomy & Foraminotomy Revision
## 479 Laparoscopic Appendectomy - 4
## 480 Laparoscopic Appendectomy - 3
## 481 Lap Band Adjustment
## 482 Laminectomy & Foraminotomy & Cervical Fusion
## 483 Laminotomy & Microdissection
## 484 Kyphoplasty & Vertebroplasty
## 485 Laminectomy & Facetectomy
## 486 Knee Arthroscopy
## 487 Knee Arthroscopy & Medial Meniscoplasty
## 488 Knee Replacement
## 489 Knee Arthroplasty - Bilateral
## 490 Knee Arthroplasty - Revision
## 491 Kyphoplasty
## 492 Knee Arthroscopy - 1
## 493 Laminectomy & Discectomy & Facetectomy
## 494 Keller Bunionectomy
## 495 Knee Amputation
## 496 Intrauterine Clots Removal
## 497 Juxtarenal Abdominal Aortic Aneurysm Repair
## 498 Knee Arthroplasty
## 499 Intraocular Lens Implant
## 500 Ischial Ulcer Debridement
## 501 Intramedullary Nail Fixation
## 502 Intramedullary Rod
## 503 Inguinal orchiopexy
## 504 Inguinal Herniorrhaphy & Circumcision
## 505 Internal Jugular Vein Catheter Insertion
## 506 Inguinal Herniorrhaphy - 2
## 507 Inguinal Herniorrhaphy - 1
## 508 Inguinal Herniorrhaphy - 3
## 509 Inguinal Hernia Repair - Indirect
## 510 Inguinal Herniorrhaphy
## 511 Inguinal Hernia Repair - 2
## 512 Inguinal Hernia Repair - 6
## 513 Inguinal Hernia Repair - 5
## 514 Inguinal Hernia Repair - 4
## 515 Inguinal Hernia Repair - 1
## 516 Inguinal Hernia Repair - 3
## 517 Inguinal Hernia Repair
## 518 Inguinal Hernia & Hydrocele Repair
## 519 Infected Toenails
## 520 Inguinal Exploration
## 521 Ingrown Toenail Removal
## 522 Iliac Crest Bone Graft - Maxilla & Mandible
## 523 Indwelling Catheter Insertion
## 524 Induction of Vaginal Delivery
## 525 I&D - Perirectal Abscess
## 526 I&D & Wound Closure - Scalp Lacerations
## 527 I&D - ORIF Wound
## 528 I&D - Penoscrotal Abscess
## 529 I&D - Neck Abscess
## 530 I&D & Open Reduction - Forearm
## 531 I&D - Gluteal Abscess
## 532 I&D & Foreign Body Removal
## 533 I&D - Buccal Space Abscess
## 534 Iliac Artery Catheter & Stent Placement, Arteriography, Angioplasty
## 535 Hysteroscopy & Laproscopy with Salpingooophorectomy
## 536 I&D - Buttock Abscess
## 537 Hysterectomy & Salpingoophorectomy
## 538 Hysteroscopy & Endometrial Ablation
## 539 I&D - Auricular Hematoma
## 540 Hypospadias Repair & Chordee Release - 1
## 541 Hysterectomy (TAH - BSO)
## 542 Hysterectomy, BSO, & Appendectomy.
## 543 Hysterectomy - Laparoscopic Supracervical
## 544 Hypergranulation - Consult
## 545 Hypospadias Repair & Chordee Release
## 546 Hydrocelectomy - 1
## 547 Hydrocelectomy
## 548 Hypospadias Repair
## 549 Hemivulvectomy
## 550 Hernia Repair
## 551 Hickman Central Venous Catheter Placement
## 552 Hydrocele Repair
## 553 Hydrocelectomy.
## 554 Hemilaminotomy & Foraminotomy
## 555 Hemodialysis Fistula Construction
## 556 Hemicraniectomy
## 557 Hemangioma Debulking & Rhinoplasty
## 558 Heart Catheterization, Ventriculography, & Angiography - 8
## 559 Hemiarthroplasty - Austin-Moore Bipolar
## 560 Hematoma Evacuation
## 561 Heart Catheterization, Ventriculography, & Angiography - 7
## 562 Heart Catheterization, Ventriculography, & Angiography - 9
## 563 Hemicolectomy
## 564 Hemiarthroplasty - Shoulder
## 565 Heart Catheterization, Ventriculography, & Angiography - 6
## 566 Heart Catheterization, Ventriculography, & Angiography - 5
## 567 Heart Catheterization, Ventriculography, & Angiography - 4
## 568 Heart Catheterization, Ventriculography, & Angiography
## 569 Heart Catheterization, Ventriculography, & Angiography - 11
## 570 Heart Catheterization, Ventriculography, & Angiography - 1
## 571 Heart Catheterization, Ventriculography, & Angiography - 12
## 572 Heart Catheterization, Ventriculography, & Angiography - 10
## 573 Heart Catheterization, Ventriculography, & Angiography - 3
## 574 Heart Catheterization & Angiography - 1
## 575 Heart Catheterization & Ventriculogram
## 576 Heart Catheterization & Angiography - 2
## 577 Heart Catheterization, Ventriculography, & Angiography - 2
## 578 Heart Catheterization & Angiography
## 579 Heart Catheterization - 2
## 580 Hardware Removal - Metatarsal
## 581 Hamstring Release
## 582 Heart Catheterization
## 583 Hallux Infected Bone Resection
## 584 Hardware Removal - Elbow
## 585 Hardware Removal - Ulnar
## 586 Heart Catheterization - 1
## 587 Heart Cath & Coronary Angiography
## 588 Granuloma Excision
## 589 G-tube placement
## 590 Gastroscopy - 3
## 591 Gangrene Surgery
## 592 Gastroscopy
## 593 Gastrostomy
## 594 Full Mouth Dental Rehabilitation - 2
## 595 Ganglion Excision
## 596 Full Mouth Dental Rehabilitation - 1
## 597 Gastroscopy - 1
## 598 Gastroscopy - 2
## 599 Foreign Object Removal - Urethra
## 600 Frontotemporoparietal Craniotomy
## 601 Foot Lesions
## 602 Foreign Body Removal - Foot
## 603 Foreign Body Removal - Foot - 1
## 604 Flexible Cystoscopy - BPH
## 605 Flexible Fiberoptic Bronchoscopy
## 606 Foreign Body Removal - Thigh
## 607 Flexor Carpi Radialis & Palmaris Longus Repair
## 608 Flexible Nasal Laryngoscopy
## 609 Frameless Stereotactic Radiosurgery
## 610 Fogarty Thrombectomy
## 611 Flexible Fiberoptic Bronchoscopy -1
## 612 Flexible Cystoscopy - Atrophic Vaginitis
## 613 Flap revision
## 614 Flex Sig - 2
## 615 Flexible Bronchoscopy
## 616 Flex Sig - 1
## 617 Fiberoptic Flexible Bronchoscopy
## 618 Fistulogram & Angioplasty
## 619 Fiberoptic Nasolaryngoscopy
## 620 Flex Sig - 3
## 621 Flex Sig
## 622 Fiberoptic Bronchoscopy with Lavage
## 623 Facet Arthrogram & Injection
## 624 Fat Harvesting
## 625 Femoral Artery Cannulation & Aortogram
## 626 Fiberoptic Bronchoscopy
## 627 Fiberoptic Bronchoscopy - 1
## 628 External Cephalic Version
## 629 Extraoral I&D
## 630 Facetectomy & Foraminotomy
## 631 Facial Laceration Closure
## 632 Eyelid Squamous Cell Carcinoma Excision
## 633 Exploratory Laparotomy - 2
## 634 Exploratory Laparotomy - 1
## 635 Extensor Tendon Repair
## 636 Exploratory Laparotomy & Colon Resection
## 637 Exploratory Laparotomy & Hernia Repair
## 638 Excision - Skin Neoplasm
## 639 Excision of Squamous Cell Carcinoma
## 640 Excision - Actinic Neoplasm
## 641 Excision - Keratotic Neoplasm
## 642 Excision - Soft Tissue Mass
## 643 Exploratory Laparotomy
## 644 Ethmoidectomy & Nasal Polypectomy
## 645 Esophagoscopy & Foreign Body Removal - 1
## 646 Excision - Hydradenitis
## 647 Esophagogastroduodenoscopy with Biopsies -2
## 648 Esophagogastroduodenoscopy with Biopsies - 1
## 649 Esophagoscopy & Foreign Body Removal
## 650 Esophagogastroduodenoscopy - 9
## 651 Esophagogastroduodenoscopy & Gastrostomy Tube Insertion
## 652 Esophagogastroduodenoscopy - 7
## 653 Esophagogastroduodenoscopy with Biopsies
## 654 Esophagogastroduodenoscopy - 8
## 655 Esophagogastroduodenoscopy - 6
## 656 Esophagogastroduodenoscopy - 4
## 657 Esophagogastroduodenoscopy - 5
## 658 Esophagogastroduodenoscopy - 13
## 659 Esophagogastroduodenoscopy - 3
## 660 Esophagogastroduodenoscopy - 2
## 661 Esophagogastroduodenoscopy - 12
## 662 Esophagogastroduodenoscopy - 11
## 663 Esophagogastroduodenoscopy - 1
## 664 Esophagogastroduodenoscopy
## 665 Esophagogastrectomy, Jejunostomy, & Chest Tubes
## 666 Esophageal Foreign Body Removal
## 667 Esophagogastroduodenoscopy - 10
## 668 ERCP
## 669 Escharotomy
## 670 Epigastric Herniorrhaphy
## 671 Epididymectomy
## 672 Endotracheal Intubation - 1
## 673 Epidermal Autograft
## 674 Epidural Hematoma Evacuation
## 675 Endovascular Abdominal Aortic Aneurysm Repair
## 676 Endotracheal Intubation
## 677 Epidurogram
## 678 Endoscopy With Biopsy
## 679 Endoscopy
## 680 Endoscopy Template
## 681 Endoscopy - 4
## 682 Endoscopic Carpal Tunnel Rlease
## 683 Endoscopy - 1
## 684 Endoscopic Carpal Tunnel & de Quervain's Release
## 685 Endoscopy - 3
## 686 Electrofulguration - Bladder Tumor
## 687 Endoscopy - 2
## 688 Endoscopic Sinus Surgery
## 689 Elbow Manipulation
## 690 Emergency C-section.
## 691 EGD with Biopsy - 1
## 692 EGD with Biopsy - 2
## 693 Electronystagmogram
## 694 EGD Template - 4
## 695 EGD with Dilation
## 696 EGD Template - 2
## 697 EGD With Photos & Biopsies.
## 698 EGD & PEG Tube Placement
## 699 EGD Template - 3
## 700 EGD & Colonoscopy
## 701 EGD - Colonoscopy - Polypectomy
## 702 EGD Template - 1
## 703 EGD - 1
## 704 EGD - 2
## 705 Ear Laceration Repair
## 706 Ear Examination
## 707 Dual Chamber ICD Implantation
## 708 Ear Cartilage Graft
## 709 Dual Chamber Generator Replacement
## 710 Dorsal Ramus & Branch Block
## 711 Dorsal Ganglion - Excision
## 712 Diverticulectomy & Laparotomy
## 713 Dupuytren Disease Excision
## 714 Dorsal Extensor Compartment Release
## 715 Double Lumen Port Inserstion
## 716 Direct Laryngoscopy
## 717 Diskectomy & Fusion
## 718 Dressing Change
## 719 Dilatation & Curettage - D&C
## 720 Discectomy, Osteophytectomy, & Foraminotomy
## 721 Dilation & Evacuation
## 722 Diskectomy
## 723 Delivery Note - 9
## 724 Dental Restorations & Extractions
## 725 Diabetic Foot Care
## 726 Diagnostic Laparoscopy - 1
## 727 Diagnostic Laparoscopy
## 728 Dental Restoration
## 729 Dental Prophylaxis
## 730 Diagnostic Arthroscopy
## 731 Delivery Note - 8
## 732 Delivery Note - 6
## 733 Delivery Note - 2
## 734 Delivery Note - 5
## 735 Delivery Note - 10
## 736 Delivery Note - 7
## 737 Delivery Note - 3
## 738 Delivery Note - 1
## 739 Debridement - Shoulder
## 740 Delayed ORIF
## 741 Delivery Note - 4
## 742 Debridement - Foot Ulcer
## 743 Delivery Note
## 744 Decompressive Laminectomy
## 745 Debridement Necrotic Tissue
## 746 DDDR Permanent Pacemaker
## 747 D&C, Laparoscopy, & Salpingectomy
## 748 Debridements
## 749 D&C & Tubal Pregnancy Removal
## 750 de Quervain Release - Carpal
## 751 de Quervain Release - Wrist
## 752 D&C & Laparoscopy - 2
## 753 D&C & Hysteroscopy Followup
## 754 D&C & Hysteroscopy - 1
## 755 D&C & Hysteroscopy
## 756 Cystourethroscopy & TURP - 1
## 757 D&C & Laparoscopy
## 758 D&C & Laparoscopy - 1
## 759 Cystourethroscopy & TURP
## 760 Cystourethroscopy & Urethral Dilation
## 761 Cystoscopy, Ureteropyelogram, & Ureteral Barbotage
## 762 Cystourethroscopy & Retrograde Pyelogram - 1
## 763 Cystourethroscopy & Retrograde Pyelogram
## 764 Cystoscopy & Visual Urethrotomy
## 765 Cystoscopy & TURP
## 766 Cystoprostatectomy
## 767 Cysto Stent Removal
## 768 Cysto & Double-J Stent Insersion
## 769 Cystolithalopaxy
## 770 Cystoscopy & Bladder Biopsy
## 771 Cystoscopy
## 772 Cystopyelogram
## 773 CT-Guided Needle Placement Biopsy
## 774 Cystopyelogram - 1
## 775 Culdoplasty & Vaginal Hysterectomy
## 776 Cystic Suprasellar Tumor Resection
## 777 CT-Guided Biopsy - Kidney
## 778 Craniotomy - Frontotemporal
## 779 Craniotomy - Temporal
## 780 Craniotomy - Frontotemporal - 1
## 781 Craniotomy - Frontal Zygomatic
## 782 Craniotomy - Retrosigmoid
## 783 Craniotomy - Occipital
## 784 Craniotomy - Biparietal
## 785 Cryosurgical Ablation of Prostate
## 786 Craniotomy & Neuronavigation
## 787 Craniotomy
## 788 Craniotomy - Burr Hole
## 789 Cranial Vault Reconstruction
## 790 Coronary Angiography & Abdominal Aortography
## 791 Control of Parapharyngeal Hemorrhage
## 792 Condylectomy
## 793 Coronary Angiography
## 794 Condyloma Cauterization
## 795 Cone Biopsy
## 796 Colonoscopy with Biopsy - 4
## 797 Colpocleisis
## 798 Completion Thyroidectomy
## 799 Colonoscopy With Photos
## 800 Complex Cyanotic Congenital Heart Disease
## 801 Colonoscopy with Biopsy
## 802 Colonoscopy with Biopsy - 2
## 803 Colonoscopy with Biopsy - 1
## 804 Colonoscopy with Biopsy - 3
## 805 Colonoscopy & Polypectomy - 3
## 806 Colonoscopy Template - 1
## 807 Colonoscopy Template - 3
## 808 Colonoscopy Template - 5
## 809 Colonoscopy Template - 4
## 810 Colonoscopy Template - 2
## 811 Colonoscopy & Polypectomy - 2
## 812 Colonoscopy - 7
## 813 Colonoscopy & Esophagogastroduodenoscopy
## 814 Colonoscopy - 6
## 815 Colonoscopy - 9
## 816 Colonoscopy & Polypectomy - 1
## 817 Colonoscopy - 5
## 818 Colonoscopy - 8
## 819 Colonoscopy - 4
## 820 Colonoscopy - 3
## 821 Colonoscopy - 21
## 822 Colonoscopy - 18
## 823 Colonoscopy - 22
## 824 Colonoscopy - 16
## 825 Colonoscopy - 17
## 826 Colonoscopy - 13
## 827 Colonoscopy - 12
## 828 Colonoscopy - 20
## 829 Colonoscopy - 2
## 830 Colonoscopy - 11
## 831 Colonoscopy - 19
## 832 Colonoscopy - 10
## 833 Colonoscopy - 15
## 834 Colonoscopy - 14
## 835 Closing Wedge Osteotomy
## 836 Coarctation of Aorta
## 837 Closed Reduction Percutaneous Pinning
## 838 Colonoscopy - 1
## 839 Closure of Amputation Wounds
## 840 Collar Tubes
## 841 Colonoscopy
## 842 Closure of Complex Lacerations
## 843 Cleft Repair
## 844 Closed ORIF - Ankle
## 845 Clear Corneal Temporal Incision
## 846 Closed Reduction - 1
## 847 Closed Reduction - 2
## 848 Closed Reduction - Mandible Fracture
## 849 Circumcision - Newborn
## 850 Cleft Repair - Soft Palate
## 851 Circumcision & Chordee Release
## 852 Circumcision - 7
## 853 Circumcision - Infant
## 854 Circumcision - 6
## 855 Circumcision - 5
## 856 Circumcision - 3
## 857 Circumcision - 1
## 858 Circumcision - 4
## 859 Cineangiography - 1
## 860 Cineangiography
## 861 Circumcision - Child
## 862 Cholecystostomy Tube Placement
## 863 Circumcision - 2
## 864 Circumcision
## 865 Cholecystectomy Laparoscopic
## 866 Cholecystectomy - Open
## 867 Cholangiopancreatography (Endoscopic)
## 868 Chest Wall Tumor Resection
## 869 Cholecystectomy & Cholangiogram.
## 870 Chest Tube Placement
## 871 Chest Closure
## 872 Chest Wall Mass Removal
## 873 Chest Tube Insertion in ER
## 874 Chest Tube Insertion
## 875 Chest Tube Removal
## 876 Cesarean Section & BTL
## 877 Cemented Arthroplasty
## 878 Cesarean Section
## 879 Cecal Polyp Resection
## 880 Cemented Hemiarthroplasty & Biopsy
## 881 Central Line Placement
## 882 Central Venous & Arterial Line
## 883 Central Line Insertion
## 884 Cauterization - Epistaxis
## 885 Catheter Placement
## 886 Cheek-Neck Facelift
## 887 Cavernosaphenous Shunt - Priapism
## 888 Cataract Surgery
## 889 Cataract Extraction - 2
## 890 Cataract Extraction & Vitrectomy
## 891 Carpal Tunnel Release - 8
## 892 Cartilage Loose Body Removal
## 893 Cataract Extraction - 1
## 894 Cataract Extraction
## 895 Carpal Tunnel Release - 6
## 896 Carpal Tunnel Release - Open
## 897 Carpal Tunnel Release - 9
## 898 Carpal Tunnel Release - 7
## 899 Carpal Tunnel Release - 4
## 900 Carpal Tunnel Release - 5
## 901 Carpal Tunnel Release - Endoscopic
## 902 Carpal Tunnel Release - 3
## 903 Carpal Ligament Release - 1
## 904 Carpal Ligament Release - 2
## 905 Carpal Tunnel Release - 2
## 906 Carotid Endarterectomy - 1
## 907 Carpal Tunnel Release
## 908 Carpal Ligament Reconstruction
## 909 Carotid Endarterectomy
## 910 Cardioversion - Direct Current - 1
## 911 Cardioversion - Unsuccessful
## 912 Cardioversion - Direct Current
## 913 Carotid Endarterectomy & Angioplasty.
## 914 Cardiac Consult & Cardioversion
## 915 Cardiac Catheterization - 8
## 916 Carious Teeth Extraction
## 917 Carpal Tunnel Release - 1
## 918 Cardioversion
## 919 Cardiac Catheterization - 9
## 920 Cardiac Catheterization - 6
## 921 Cardiac Catheterization - 3
## 922 Cardiac Catheterization - 5
## 923 Cardiac Catheterization - 7
## 924 Cardiac Catheterization - 12
## 925 Cardiac Catheterization - 10
## 926 Cardiac Catheterization
## 927 Cardiac Catheterization - 2
## 928 Cardiac Catheterization - 4
## 929 Cardiac Cath & Coronary Angiography
## 930 Cardiac Catheterization - 11
## 931 Cardiac Cath & Selective Coronary Angiography
## 932 Calcaneal Lengthening Osteotomy
## 933 Capsulotomy & Flat Advancement, Left Breast
## 934 CABG - 2
## 935 Cardiac Allograft Transplant
## 936 Cardiac Catheterization - 1
## 937 CABG - Redo
## 938 CABG x4
## 939 CABG - 1
## 940 CABG
## 941 Bunionectomy & Arthrodesis
## 942 Bunionectomy & Metatarsal Osteotomy
## 943 Bunionectomy & Akin Osteotomy
## 944 Bunionectomy - Austin - Akin
## 945 Bunions and Calluses
## 946 Buccal Mucosal Lesion Excision
## 947 Bunionectomy & Osteotomy
## 948 BTL & Salpingectomy
## 949 Bunionectomy & Flexor Tenotomy
## 950 Broviac Catheter Placement
## 951 Browlift, Blepharoplasty, & Rhytidectomy
## 952 Bronchoscopy & Foreign Body Removal
## 953 Bronchoscopy - 8
## 954 Bronchoscopy & Lobectomy
## 955 Bronchoscopy & Bronchoalveolar Lavage
## 956 Bronchoscopy - 7
## 957 Bronchoscopy Brushings
## 958 Bronchoscopy - Fiberoptic
## 959 Bronchoscopy & Thoracotomy
## 960 Bronchoscopy - 6
## 961 Bronchoscopy - 2
## 962 Bronchoscopy - 4
## 963 Breast Mass Excision - 2
## 964 Bronchoscopy - 1
## 965 Bronchoscopy - 5
## 966 Bronchoalveolar lavage.
## 967 Breast Excisional Biopsy
## 968 Bronchoscopy - 3
## 969 Breast Mass Excision - 1
## 970 Bronchoscopy
## 971 Breast Biopsy
## 972 Breast Biopsy - 2
## 973 Breast Biopsy - 1
## 974 Breast Mass Excision
## 975 Brachytherapy
## 976 BMT & T&A
## 977 Bone Removal - Metatarsal Head
## 978 Bony Impacted Teeth Removal
## 979 BMT & Adenoidectomy
## 980 Brain Stimulator Electrode
## 981 Blepharoplasty - Lower Lid
## 982 Bone Impacted Tooth Removal
## 983 Blepharoplasty - Direct Brow Repair
## 984 Blepharoplasty - Quad
## 985 Biopsy - Skin Nevus
## 986 Biopsy - Axillary Lymph Node
## 987 Blepharon & Entropion Repair
## 988 Biventricular Cardioverter Defibrillator Implantation
## 989 Bladder Biopsies & Fulguration
## 990 Biopsy - Cervical Lymph Node
## 991 Blepharoplasty
## 992 Bladder Laceration Closure
## 993 BioArc Midurethral Sling
## 994 Bilateral Vasovasostomy
## 995 Biopsy - Actinic Keratosis
## 996 Bilateral Orbital Frontozygomatic Craniotomy
## 997 Bilateral Tubal Occlusion - Laparoscopic
## 998 Bilateral Myringotomies
## 999 Bilateral Myringotomies - 1
## 1000 Bilateral Inguinal Herniorrhaphy
## 1001 Bilateral Upper Lid Blepharoplasty
## 1002 Bilateral Myringotomies - 2
## 1003 Bilateral Carotid Cerebral Angiogram
## 1004 Biceps Tendon Repair
## 1005 Belly Button Piercing
## 1006 BICAP Cautery
## 1007 BCCa Excision - Cheek
## 1008 Bifrontal Cranioplasty
## 1009 BCCa Excision - Lower Lid
## 1010 BCCa Excision - Nasal Tip
## 1011 BCCa Excision - Canthus
## 1012 Basilic Vein Transposition
## 1013 AV Fistula - 4
## 1014 Axillary Dissection & Mass Excision
## 1015 AV Fistula - 5
## 1016 AV Fistula - 3
## 1017 AV Fistula - 2
## 1018 Bbunionectomy & Metatarsal Osteotomy
## 1019 AV Fistula - 1
## 1020 Austin-Moore Bipolar Hemiarthroplasty
## 1021 Austin Bunionectomy
## 1022 Atrioventricular Septal Defect
## 1023 Austin-Akin Bunionectomy
## 1024 Aspiration - Knee Joint
## 1025 Ash Split Venous Port
## 1026 Arthrotomy & I&D
## 1027 Arthroscopy, Meniscoplasty, & Chondroplasty
## 1028 Arthrotomy & Subscapularis Tendon Repair
## 1029 Arthroscopy, Arthrotomy, Bankart lesion repair
## 1030 Arthrotomy & Ostectomy & Capsular Mass Excision
## 1031 Arthroscopy - Shoulder
## 1032 Arthroscopy & Chondroplasty
## 1033 Arthroscopic SLAP lesion
## 1034 Arthroscopic Rotator Cuff Repair - 2
## 1035 Arthroscopy - Glenoid Labrum
## 1036 Arthroscopic Subacromial Decompression - Shoulder
## 1037 Arthroscopy Shoulder/Knee
## 1038 Arthroscopic Rotator Cuff Repair
## 1039 Arthroscopic Debridement - Shoulder
## 1040 Arthroplasty - Hammertoe
## 1041 Arthroplasty
## 1042 Arthroscopic Meniscoplasty
## 1043 Appendectomy Laparoscopic
## 1044 Arthroscopic Debridement & Labral Repair - Hip
## 1045 Appendectomy Laparoscopic - 1
## 1046 Arthrodesis
## 1047 Appendectomy - 1
## 1048 Appendectomy - 2
## 1049 Aortobifemoral Bypass
## 1050 Aortogram - Leg claudication.
## 1051 Arthroscopic Rotator Cuff Repair - 1
## 1052 Aortic Valve Replacement
## 1053 Appendectomy - Laparoscopic
## 1054 Appendectomy
## 1055 Antibiotic-Impregnated Beads Placement
## 1056 Aortobifemoral Bypass - 1
## 1057 Anterior Cervical Discectomy & Interbody Fusion - 3
## 1058 Anterior Cervical Discectomy & Interbody Fusion - 2
## 1059 Anterior Lumbar Fusion
## 1060 Anterior Cruciate Ligament Reconstruction
## 1061 Anterior Cervical Discectomy & Fusion - 8
## 1062 Anterior Cervical Discectomy & Osteophytectomy
## 1063 Anterior Cervical Discectomy & Interbody Fusion
## 1064 Anterior Cervical Discectomy & Fusion - 7
## 1065 Anterior Cervical Discectomy & Interbody Fusion - 1
## 1066 Anterior Cervical Discectomy & Fusion - 9
## 1067 Anterior Cervical Discectomy & Fusion - 6
## 1068 Anterior Cervical Discectomy & Fusion
## 1069 Anterior Cervical Discectomy & Fusion - 5
## 1070 Anterior Cervical Discectomy & Fusion - 4
## 1071 Anterior Cervical Discectomy & Fusion - 3
## 1072 Anterior Cervical Discectomy & Fusion - 2
## 1073 Anterior Cervical Discectomy & Decompression
## 1074 Anterior Cervical Discectomy & Decompression - 1
## 1075 Anterior Cervical Discectomy & Fusion - 1
## 1076 Anterior Cervical Discectomy & Arthrodesis - 2
## 1077 Anterior Cervical Discectomy - 2
## 1078 Anterior Cervical Discectomy & Arthrodesis
## 1079 Anterior Cervical Decompression
## 1080 Anterior Cervical Discectomy & Arthrodesis - 1
## 1081 Anterior Cervical Discectomy - 1
## 1082 Anterior Cervical Discectomy - 4
## 1083 Anterior Cervical Discectomy - 3
## 1084 Anterior Cervical Discectomy
## 1085 Angiography & Catheterization - 1
## 1086 Adenotonsillectomy
## 1087 Adenoidectomy - 1
## 1088 Ahmed Shunt Placement
## 1089 Adrenalectomy & Umbilical Hernia Repair
## 1090 Angiography & Catheterization
## 1091 Angiogram & Angioplasty
## 1092 Adenocarcinoma & Mesothelioma
## 1093 Adenoidectomy
## 1094 Adenotonsillectomy - 2
## 1095 Adenotonsillectomy - 1
## 1096 Achilles Lengthening
## 1097 Adenoidectomy & Tonsillectomy & Lingual Frenulectomy
## 1098 Achilles Tendon Repair
## 1099 AC Separation Revision & Hardware Removal
## 1100 Abscess Excision
## 1101 Abdominal Exploration
## 1102 Abdominal Abscess I&D
## 1103 Abdominosacrocolpopexy
## 1104 Ultrasound Scrotum
## 1105 X-RAY - Neck Soft Tissues
## 1106 Ultrasound OB - 5
## 1107 Whole Body Radionuclide Bone Scan
## 1108 Ultrasound OB - 7
## 1109 Ultrasound OB - 8
## 1110 Ultrasound OB - 6
## 1111 Ultrasound OB - 4
## 1112 Ultrasound OB - 3
## 1113 Ultrasound OB - 2
## 1114 Ultrasound - Pelvis
## 1115 Ultrasound - Transvaginal
## 1116 Ultrasound OB - 1
## 1117 Ultrasound - Lower Extremity
## 1118 Ultrasound - Kidney
## 1119 Ultrasound - Lower Extremity - 1
## 1120 Ultrasound - Carotid - 2
## 1121 Ultrasound OB
## 1122 Ultrasound - Neck Soft Tissue
## 1123 Transesophageal Echocardiogram - 6
## 1124 Transthoracic Echocardiography
## 1125 Ultrasound - Abdomen - 1
## 1126 Transesophageal Echocardiogram - 4
## 1127 Ultrasound - Carotid - 1
## 1128 Ultrasound - Abdomen
## 1129 Transesophageal Echocardiogram - 5
## 1130 Transesophageal Echocardiogram - 1
## 1131 Testicular Ultrasound
## 1132 Tun-L Catheter Placement
## 1133 Transesophageal Echocardiogram
## 1134 Transesophageal Echocardiogram - 3
## 1135 Transesophageal Echocardiogram - 2
## 1136 Three Views - Ankle
## 1137 Tailor Bunionectomy with Screw Fixation
## 1138 Three Views - Foot
## 1139 Stress Test Graded Exercise Treadmill
## 1140 Stress Test Thallium
## 1141 Stress Test Bruce Protocol
## 1142 Stress Test Dobutamine Myoview
## 1143 Stress Test Dobutrex
## 1144 Stress Test Dobutamine
## 1145 Slipped Capital Femoral Epiphysis (SCFE)
## 1146 Stress Test Adenosine Myoview
## 1147 SAH, Contusion, Skull Fracture
## 1148 Single Frontal View of Chest
## 1149 Single Frontal View - Chest - Pediatric
## 1150 Radiofrequency Thermocoagulation - 2
## 1151 Renal Ultrasound
## 1152 Radionuclide Stress Test
## 1153 Radiofrequency Thermocoagulation - 1
## 1154 Renal Ultrasound - 1
## 1155 Radiofrequency Thermocoagulation
## 1156 Radiologic Exam - Spine
## 1157 Prostate Brachytherapy
## 1158 Right Foot Series
## 1159 Paracentesis - Ultrasound-Guided
## 1160 Nuclear Medicine Lymphatic Scan
## 1161 Nuclear Cardiac Stress Report
## 1162 PET Report - Whole Body Scan
## 1163 Nuclear Medicine Tumor Localization
## 1164 Radiofrequency Ablation
## 1165 Myoview Perfusion Scan
## 1166 MRI T-Spine - Spinal Mets
## 1167 Myocardial Perfusion Imaging - 1
## 1168 Myocardial Perfusion Imaging - 3
## 1169 MRI Wrist - 1
## 1170 Multiple Images of Skull (Pediatric)
## 1171 Normal L-Spine MRI
## 1172 Myocardial Perfusion Imaging - 2
## 1173 MRI T-Spine - 1
## 1174 MRI T-Spine
## 1175 MRI Shoulder - 2
## 1176 MRI T-L Spine - Schistosomiasis
## 1177 MRI Spine - Epidural Lipoma
## 1178 MRI Shoulder - 4
## 1179 MRI Shoulder - 5
## 1180 MRI Shoulder - 3
## 1181 MRI Spine
## 1182 MRI of Brain w/o Contrast.
## 1183 MRI of Lumbar Spine w/o Contrast
## 1184 MRI L-Spine - Subarachnoid Seeding
## 1185 MRI Orbit/Face/Neck
## 1186 MRI Shoulder - 1
## 1187 MRI of Lung - Adenocarcinoma
## 1188 MRI L-S Spine - Cauda Equina Syndrome
## 1189 MRI Knee - 4
## 1190 MRI Knee - 3
## 1191 MRI Knee - 5
## 1192 MRI Foot - 1
## 1193 MRI Head
## 1194 MRI Foot - 3
## 1195 MRI Knee - 2
## 1196 MRI Head - 1
## 1197 MRI Knee - 1
## 1198 MRI Foot - 2
## 1199 MRI Elbow - 2
## 1200 MRI Cervical Spine - Chiropractic Specific
## 1201 MRI C-spine
## 1202 MRI C-Spine - C5-6 Disk Herniation
## 1203 MRI Elbow - 1
## 1204 MRI C3 - Cord Compression.
## 1205 MRI Cervical Spine - 1
## 1206 MRI Brain: Thalamic Infarct
## 1207 MRI Cervical Spine - 2
## 1208 MRI Brain & T-spine - Demyelinating disease.
## 1209 MRI Brain and C-T Spine
## 1210 MRI Breast - 1
## 1211 MRI Brain and Brainstem
## 1212 MRI Brain & Cerebral Angiogram
## 1213 MRI Brain - Thrombus
## 1214 MRI Brain - Wernicke aphasia
## 1215 MRI Brain - SLE & Stroke
## 1216 MRI Brain - Pontine Stroke
## 1217 MRI Brain - Memory Loss
## 1218 MRI Brain - Lyme Disease
## 1219 MRI Brain - Progressive Aphasia
## 1220 MRI Brain - Toxoplasmosis
## 1221 MRI Brain - Bilateral Thalamic Strokes
## 1222 MRI Brain - Leukoencephalopathy
## 1223 MRI Brain - Pilocytic Astrocytoma
## 1224 MRI Brain - CO poisoning
## 1225 MRI Brain - Meningioma (Olfactory)
## 1226 MRI Ankle - 2
## 1227 Moyamoya Disease
## 1228 MRI Brain - Cryptococcus
## 1229 MRI Ankle - 1
## 1230 Mayoview - 2
## 1231 Lower Extremity Venous Doppler
## 1232 Lexiscan Nuclear Scan
## 1233 Mayoview - 1
## 1234 Magnified Airway Study
## 1235 Lumbar Discogram
## 1236 Mayoview
## 1237 Lower Extremity Arterial Doppler
## 1238 Laparoscopy - Drainage of Cyst
## 1239 IV Procainamide Infusion
## 1240 Intraarterial Particulate Administration
## 1241 Laparoscopic Cholecystectomy & Cholangiogram
## 1242 HCT - Pituitary Mass
## 1243 Intensity-Modulated Radiation Therapy Simulation
## 1244 Hepatobiliary Scan
## 1245 Intensity-Modulated Radiation Therapy
## 1246 Full-Field Digital Mammogram (FFDM) - 1
## 1247 Hyperfractionation
## 1248 Five views of the right knee.
## 1249 HDR Brachytherapy
## 1250 Full-Field Digital Mammogram (FFDM) - 2
## 1251 Facet Arthrogram & Injection
## 1252 HCT - Calcification of Basal Ganglia
## 1253 Exercise Myocardial Perfusion Study
## 1254 Endovascular Brachytherapy
## 1255 EMG/Nerve Conduction Study - 9
## 1256 EMG/Nerve Conduction Study - 5
## 1257 Fetal Anatomical Survey
## 1258 EMG/Nerve Conduction Study - 8
## 1259 Excretory Urogram - IVP
## 1260 EMG/Nerve Conduction Study - 3
## 1261 EMG/Nerve Conduction Study - 7
## 1262 EMG/Nerve Conduction Study - 4
## 1263 EMG/Nerve Conduction Study - 6
## 1264 EMG/Nerve Conduction Study - 2
## 1265 EEG Monitoring Study
## 1266 Echocardiogram - 3
## 1267 Electronystagmogram
## 1268 EMG/Nerve Conduction Study
## 1269 Echocardiography
## 1270 EMG/Nerve Conduction Study - 1
## 1271 Echocardiogram - 1
## 1272 EEG
## 1273 Echocardiogram
## 1274 Echocardiogram - 2
## 1275 Duplex Ultrasound - Legs
## 1276 Dobutamine Stress Test - 1
## 1277 Diagnostic Cerebral Angiogram
## 1278 Diagnostic Mammogram
## 1279 Dandy-Walker Malformation
## 1280 CT-Guided Needle Placement Biopsy
## 1281 CT-Guided Biopsy - Kidney
## 1282 Deglutition Study - Modified Barium swallow
## 1283 Dobutamine Stress Test
## 1284 CT Scan of Brain with Contrast
## 1285 CT Stone Protocol
## 1286 CT Scan of Brain w/o Contrast
## 1287 CT Scan of Abdomen & Pelvis with Contrast
## 1288 CT of Chest with Contrast
## 1289 CT of Facial Wones w/o Contrast
## 1290 CT of Lumbar Spine w/o Contrast
## 1291 CT Maxillofacial
## 1292 CT Neck - 2
## 1293 CT Neck - 1
## 1294 CT Lumbar Spine - 2
## 1295 CT Neck
## 1296 CT Head, Facial Bones, Cervical Spine - 1
## 1297 CT Head, Facial Bones, Cervical Spine
## 1298 CT Head - 2
## 1299 CT Head - 3
## 1300 CT Lumbar Spine
## 1301 CT Lumbar Spine - 1
## 1302 CT Head
## 1303 CT Facial
## 1304 CT KUB
## 1305 CT C-Spine - 2
## 1306 CT Head - 1
## 1307 CT C-Spine - 1
## 1308 CT Head - 4
## 1309 CT Head and C Spine
## 1310 CT Chest
## 1311 CT C-Spine
## 1312 CT Brain - Stroke
## 1313 CT Chest - 2
## 1314 CT Brain: Subdural hematoma
## 1315 CT Chest - 1
## 1316 CT Brain - SAH
## 1317 CT Brain - Hemangioma
## 1318 CT Brain: Subdural Hemorrhage.
## 1319 CT Brain - Calcification of Basal Ganglia
## 1320 CT Brain - Aneurysm
## 1321 CT Abdomen & Pelvis - OB-GYN
## 1322 CT Abdomen & Pelvis - 7
## 1323 CT Abdomen & Pelvis - 8
## 1324 CT Angiography
## 1325 CT Abdomen & Pelvis - 5
## 1326 CT Angiography - 1
## 1327 CT Abdomen & Pelvis - 6
## 1328 CT Brain
## 1329 CT Abdomen & Pelvis - 9
## 1330 CT Abdomen & Pelvis - 10
## 1331 CT Abdomen & Pelvis - 4
## 1332 CT Abdomen & Pelvis - 2
## 1333 CT Abdomen & Pelvis - 11
## 1334 CT Abdomen & Pelvis - 3
## 1335 CT Abdomen & Pelvis - 1
## 1336 Coronary CT Angiography (CCTA) - 5
## 1337 CT Abdomen & Pelvis
## 1338 Coronary CT Angiography (CCTA) - 2
## 1339 Coronary CT Angiography (CCTA) - 3
## 1340 Conformal Simulation
## 1341 Coronary CT Angiography (CCTA) - 4
## 1342 Coronary CT Angiography (CCTA) - 1
## 1343 Chest PA & Lateral
## 1344 Cerebral Angiogram & MRA
## 1345 Chest CT - Myasthenia Gravis
## 1346 Cerebral Angiogram - Left ICA/PCA Aneurysm
## 1347 Chest Pulmonary Angio
## 1348 Cerebral Angiogram - Lateral Medullary Syndrome
## 1349 Concomitant Chemoradiotherapy
## 1350 Cardiac Radionuclide Stress Test
## 1351 Carotid & Cerebral Arteriograms
## 1352 Cardiolite Treadmill Stress Test
## 1353 Cerebral Angiogram
## 1354 Carotid Ultrasound
## 1355 Carotid Doppler Report
## 1356 Bilateral Mammogram
## 1357 Bilateral Carotid Angiography
## 1358 Biophysical Profile - 1
## 1359 Breast Ultrasound & Biopsy
## 1360 Biophysical Profile
## 1361 Brain MRI - Pituitary Adenoma
## 1362 Barium Enema
## 1363 Arterial Imaging
## 1364 Alzheimer Disease
## 1365 Angiogram & StarClose Closure
## 1366 Arachnoid Cyst
## 1367 Adenosine Nuclear Scan
## 1368 Acute Intracerebral Hemorrhage
## 1369 AVM with Hemorrhage
## 1370 Astrocytoma
## 1371 2-D Echocardiogram - 2
## 1372 3-Dimensional Simulation
## 1373 2-D Echocardiogram - 3
## 1374 2-D Echocardiogram - 4
## 1375 2-D Echocardiogram - 1
## 1376 2-D Doppler
## 1377 Youngswick Osteotomy
## 1378 Youngswick Bunionectomy
## 1379 Wrist Pain
## 1380 Wrist Ganglion Excision
## 1381 Vertebroplasty
## 1382 Trigger Thumb Release - 1
## 1383 Ulnar Nerve Transposition & Olecranon Bursa Excision
## 1384 Ulnar Nerve Transposition
## 1385 Trigger Finger Release
## 1386 Ulnar Nerve Decompression
## 1387 Total Knee Replacement - 1
## 1388 Total Knee Arthroplasty - Right
## 1389 Total Knee Replacement
## 1390 Trigger Thumb Release
## 1391 Total Knee Arthroplasty
## 1392 Transpedicular Decompression
## 1393 Total Hip Arthroplasty
## 1394 Total Hip Replacement - 1
## 1395 Total Knee Arthoplasty - Right - 1
## 1396 Total Hip Replacement
## 1397 Total Knee Replacement - NexGen
## 1398 TLIF
## 1399 Total Hip Arthroplasty - Revision
## 1400 Tissue Expander Insertion
## 1401 Three Views - Ankle
## 1402 Three Views - Foot
## 1403 Tenosynovectomy & Cortisone Injection
## 1404 Tarsectomy
## 1405 Tailor Bunionectomy with Screw Fixation
## 1406 Symes Amputation - Hallux
## 1407 Synovectomy - Partial
## 1408 Styloidectomy
## 1409 Spinal Fusion & Instrumentation
## 1410 Thoracic Discectomy
## 1411 Subperiosteal Abscess Debridement
## 1412 Subcutaneous Transposition of Ulnar Nerve
## 1413 Spine Fusion
## 1414 Superior Labrum Lesions Repair
## 1415 Spinal Manipulation
## 1416 Slipped Capital Femoral Epiphysis (SCFE)
## 1417 Rotator Cuff Repair
## 1418 Shoulder Contusion
## 1419 Shoulder Pain Consult
## 1420 Rotator Cuff Tear
## 1421 Scarf Bunionectomy
## 1422 Shoulder Hemi-resurfacing
## 1423 Right Shoulder Hemiarthroplasty
## 1424 Rotator cuff syndrome - H&P
## 1425 Release of A1 Pulley - 1
## 1426 Rheumatology Progress Note
## 1427 Release of A1 Pulley
## 1428 PMT Halo Crown & Vest
## 1429 RICE Therapy
## 1430 Radiologic Exam - Spine
## 1431 Pinning - Ulna
## 1432 Records Review - Orthopedic
## 1433 Radiofrequency Ablation
## 1434 Pilon Fracture External Fixation
## 1435 Pinning - Hip
## 1436 Phalanx Amputation
## 1437 Pectoralis Tendon Repair
## 1438 Physical Therapy - Back Pain
## 1439 Pathology - Sesamoid Bone
## 1440 Physical Therapy - Synovitis
## 1441 Physical Therapy - Osteoarthritis
## 1442 Pediatric Rheumatology Consult
## 1443 Physical Therapy - Low Back Pain
## 1444 Patellar Tendon & Retinaculum Repair
## 1445 Physical Therapy - Ankle Sprain
## 1446 Pain Management Progress Note
## 1447 Osteotomy & Bunionectomy
## 1448 Pain Management Consult - 1
## 1449 Osteotomy & Bunionectomy - 1
## 1450 Osteoarthritis - Progress Note
## 1451 OssaTron Extracorporeal Shockwave Therapy
## 1452 Osteosynthesis
## 1453 Orthopedic Consult - 5
## 1454 Orthopedic Consult - 4
## 1455 Orthopedic Consult - 3
## 1456 Orthopedic Consult - 2
## 1457 Pain Management Consult - 2
## 1458 Orthopedic Consult
## 1459 Orthopedic Consult - 1
## 1460 Ortho - Letter - 1
## 1461 ORIF Wrist - Acumed Locking Plate
## 1462 Ortho Office Visit
## 1463 ORIF & Cervical Fusion
## 1464 ORIF & Closed Reduction
## 1465 ORIF Mandibular Fracture & Dental Implant Removal
## 1466 ORIF, Closed Reduction, Screw Fixation, Etc.
## 1467 Ortho - Letter - 2
## 1468 ORIF of Left Distal Radius
## 1469 ORIF - Left Tibia
## 1470 ORIF - Followup
## 1471 ORIF - Talus
## 1472 ORIF - Malleolus
## 1473 ORIF - 2
## 1474 ORIF - 3
## 1475 ORIF - Fifth Metatarsal
## 1476 ORIF - 1
## 1477 Normal L-Spine MRI
## 1478 Nerve & Tendon Repair - Finger
## 1479 ORIF - Discharge Summary
## 1480 Neuroplasty
## 1481 Olecranon Bursa - Excision
## 1482 Open Plantar Fasciotomy
## 1483 Neck Pain - Discharge Summary
## 1484 Neck & Back Pain
## 1485 MRI T-Spine - Spinal Mets
## 1486 MRI Wrist - 1
## 1487 MRI T-Spine
## 1488 MRI T-Spine - 1
## 1489 Mumford Procedure & Acromioplasty
## 1490 Neck & Lower Back Pain - Consult
## 1491 MRI T-L Spine - Schistosomiasis
## 1492 MRI Shoulder - 5
## 1493 MRI Spine - Epidural Lipoma
## 1494 MRI Shoulder - 4
## 1495 MRI Spine
## 1496 MRI of Lumbar Spine w/o Contrast
## 1497 MRI L-Spine - Subarachnoid Seeding
## 1498 MRI Knee - 5
## 1499 MRI Knee - 3
## 1500 MRI Shoulder - 3
## 1501 MRI Shoulder - 2
## 1502 MRI L-S Spine - Cauda Equina Syndrome
## 1503 MRI Shoulder - 1
## 1504 MRI Knee - 1
## 1505 MRI Knee - 2
## 1506 MRI Foot - 2
## 1507 MRI Knee - 4
## 1508 MRI Foot - 3
## 1509 MRI Foot - 1
## 1510 MRI C-spine
## 1511 MRI Elbow - 2
## 1512 MRI Elbow - 1
## 1513 MRI Cervical Spine - 2
## 1514 MRI Brain and C-T Spine
## 1515 MRI C-Spine - C5-6 Disk Herniation
## 1516 MRI Cervical Spine - 1
## 1517 MRI Ankle - 2
## 1518 MRI C3 - Cord Compression.
## 1519 MRI Cervical Spine - Chiropractic Specific
## 1520 MRI Ankle - 1
## 1521 MRI Brain & T-spine - Demyelinating disease.
## 1522 McBride Bunionectomy & Wedge Osteotomy
## 1523 Meniscoplasty & Chondroplasty
## 1524 Lumbar Radiculopathy - Consult
## 1525 Lumbar Re-exploration
## 1526 Medial Branch Rhizotomy
## 1527 Lumbar Laminectomy & Discectomy
## 1528 Lumbar Spine HNP - Consult
## 1529 Lumbar Laminectomy
## 1530 Lumbar Puncture - 2
## 1531 Lumbar Discogram
## 1532 Lower back pain
## 1533 Lumbar Discectomy - Microscopic
## 1534 Low Back Pain - Consult
## 1535 Lumbar Laminotomy & Discectomy
## 1536 Lower Extremity Pain
## 1537 Ligament Reconstruction & Tendon Interposition Arthroplasty
## 1538 Long-Arm Cast
## 1539 Ligament Reconstruction & Meniscus Repair
## 1540 Lateral Epicondylitis Release
## 1541 Laminotomy, Facetectomy & Foraminotomy
## 1542 Leg Pain - Progress Note
## 1543 Laminectomy & Facetectomy
## 1544 Laminectomy & Foraminotomy Followup
## 1545 Kyphosis
## 1546 Laminectomy & Discectomy & Facetectomy
## 1547 Laminectomy & Foraminotomy Revision
## 1548 Laminectomy & Foraminotomy & Cervical Fusion
## 1549 Kyphoplasty
## 1550 Knee Replacement
## 1551 Kyphoplasty - Consult
## 1552 Knee Surgery - Discharge Summary
## 1553 Kyphoplasty & Vertebroplasty
## 1554 Knee Arthroscopy & Medial Meniscoplasty
## 1555 Knee Injury
## 1556 Knee Arthroscopy
## 1557 Knee Arthroscopy - 1
## 1558 Knee Arthroplasty - Discharge Summary
## 1559 Knee DJD - Consult
## 1560 Knee & Back Pain
## 1561 Knee Arthroplasty - Revision
## 1562 Knee Amputation
## 1563 Knee Osteoarthrosis - Discharge Summary
## 1564 Knee Arthroplasty
## 1565 Intramedullary Nail Fixation
## 1566 Intramedullary Rod
## 1567 Knee Arthroplasty - Bilateral
## 1568 IME & Record Review - Orthopedic
## 1569 I&D & Open Reduction - Forearm
## 1570 I&D - ORIF Wound
## 1571 Hip Pain
## 1572 I&D & Foreign Body Removal
## 1573 Hypergranulation - Consult
## 1574 Ingrown Toenail Removal
## 1575 Hip Surgery - Discharge Summar
## 1576 Hip Fracture - Rehab Consult
## 1577 Hemiarthroplasty - Shoulder
## 1578 Hemilaminotomy & Foraminotomy
## 1579 Hip Fracture - ER Consult
## 1580 Hemiarthroplasty - Austin-Moore Bipolar
## 1581 Hemiarthroplasty - Discharge Summary
## 1582 Hardware Removal - Elbow
## 1583 Hand Pain - Consult
## 1584 Hardware Removal - Metatarsal
## 1585 Hardware Removal - Ulnar
## 1586 Hamstring Release
## 1587 Foreign Body Removal - Foot
## 1588 Ganglion Excision
## 1589 Foot pain Consultation
## 1590 Hallux Infected Bone Resection
## 1591 Foreign Body Removal - Foot - 1
## 1592 Flexor Carpi Radialis & Palmaris Longus Repair
## 1593 FCR tendinitis
## 1594 Five views of the right knee.
## 1595 Endoscopic Carpal Tunnel Rlease
## 1596 Extensor Tendon Repair
## 1597 Facetectomy & Foraminotomy
## 1598 Finger triggering and locking
## 1599 Endoscopic Carpal Tunnel & de Quervain's Release
## 1600 Followup Screw Fixation
## 1601 Elbow Manipulation
## 1602 Dupuytren Disease Excision
## 1603 Dorsal Ganglion - Excision
## 1604 Elbow Pain - Consult
## 1605 Discharge Summary - Hip Surgery
## 1606 Discectomy, Osteophytectomy, & Foraminotomy
## 1607 Dorsal Extensor Compartment Release
## 1608 Discharge Summary - ATV Accident
## 1609 Dorsal Ramus & Branch Block
## 1610 Diskectomy
## 1611 Decompressive Laminectomy
## 1612 de Quervain Release - Wrist
## 1613 Diskectomy & Fusion
## 1614 Delayed ORIF
## 1615 Diagnostic Arthroscopy
## 1616 Debridement - Shoulder
## 1617 de Quervain Release - Carpal
## 1618 CT Neck - 1
## 1619 CT Lumbar Spine
## 1620 CT of Lumbar Spine w/o Contrast
## 1621 CT Lumbar Spine - 1
## 1622 CT Lumbar Spine - 2
## 1623 CT Neck - 2
## 1624 CT Head, Facial Bones, Cervical Spine - 1
## 1625 CT C-Spine
## 1626 CT Head and C Spine
## 1627 CT Head, Facial Bones, Cervical Spine
## 1628 Consult - Back & Leg Pain
## 1629 Condylectomy
## 1630 Closed Reduction Percutaneous Pinning
## 1631 Consult - Knee Pain
## 1632 CT C-Spine - 1
## 1633 CT C-Spine - 2
## 1634 Closed ORIF - Ankle
## 1635 Closed Reduction - 1
## 1636 Cervicalgia
## 1637 Closing Wedge Osteotomy
## 1638 Cemented Hemiarthroplasty & Biopsy
## 1639 Cervical Spondylosis - Neuro Consult
## 1640 Closed Reduction - 2
## 1641 Carpal Tunnel Release - Endoscopic
## 1642 Cartilage Loose Body Removal
## 1643 Carpal Tunnel Release - Open
## 1644 Cervical Spinal Stenosis
## 1645 Cemented Arthroplasty
## 1646 Carpal Tunnel Release - 9
## 1647 Carpal Tunnel Release - 6
## 1648 Carpal Tunnel Release - 7
## 1649 Carpal Tunnel Release - 8
## 1650 Carpal Tunnel Release - 5
## 1651 Carpal Tunnel Release - 2
## 1652 Carpal Tunnel Release - 4
## 1653 Carpal Tunnel Release - 1
## 1654 Carpal Ligament Reconstruction
## 1655 Carpal Ligament Release - 1
## 1656 Carpal Tunnel Release - 3
## 1657 Calcaneal Lengthening Osteotomy
## 1658 Carpal Tunnel Release
## 1659 Bunionectomy & Metatarsal Osteotomy
## 1660 Bunionectomy & Osteotomy
## 1661 Carpal Ligament Release - 2
## 1662 Bunionectomy & Akin Osteotomy
## 1663 Bunionectomy & Arthrodesis
## 1664 Bunionectomy & Flexor Tenotomy
## 1665 Bunion & Pes Planovalgus Deformity
## 1666 Bunionectomy - Austin - Akin
## 1667 Bilateral Hip Pain
## 1668 Back Pain - Discharge Summary
## 1669 Bbunionectomy & Metatarsal Osteotomy
## 1670 Back Injury IME
## 1671 Back & Leg Pain - Discharge Summary
## 1672 Biceps Tendon Repair
## 1673 Austin-Moore Bipolar Hemiarthroplasty
## 1674 Arthroscopy, Arthrotomy, Bankart lesion repair
## 1675 Austin Bunionectomy
## 1676 Arthrotomy & I&D
## 1677 Arthrotomy & Ostectomy & Capsular Mass Excision
## 1678 Austin-Akin Bunionectomy
## 1679 Aspiration - Knee Joint
## 1680 Arthroscopy, Meniscoplasty, & Chondroplasty
## 1681 Arthrotomy & Subscapularis Tendon Repair
## 1682 Arthroscopy - Shoulder
## 1683 Arthroscopy Shoulder/Knee
## 1684 Arthroscopy - Glenoid Labrum
## 1685 Arthroscopic Rotator Cuff Repair
## 1686 Arthroscopy & Chondroplasty
## 1687 Arthroscopic Meniscoplasty
## 1688 Arthroscopic Rotator Cuff Repair - 1
## 1689 Arthroscopic Rotator Cuff Repair - 2
## 1690 Arthroscopic SLAP lesion
## 1691 Arthroscopic Debridement & Labral Repair - Hip
## 1692 Arthroplasty - Hammertoe
## 1693 Arthroscopic Debridement - Shoulder
## 1694 Anterior Lumbar Fusion
## 1695 Arthroplasty
## 1696 Anterior Cervical Discectomy & Interbody Fusion - 1
## 1697 Arthrodesis
## 1698 Antibiotic-Impregnated Beads Placement
## 1699 Anterior Cruciate Ligament Reconstruction
## 1700 Anterior Cervical Discectomy & Interbody Fusion - 3
## 1701 Anterior Cervical Discectomy & Interbody Fusion - 2
## 1702 Anterior Cervical Discectomy & Fusion - 8
## 1703 Anterior Cervical Discectomy & Fusion - 7
## 1704 Anterior Cervical Discectomy & Interbody Fusion
## 1705 Anterior Cervical Discectomy & Fusion - 9
## 1706 Anterior Cervical Discectomy & Fusion - Discharge Summary
## 1707 Anterior Cervical Discectomy & Osteophytectomy
## 1708 Anterior Cervical Discectomy & Fusion - 6
## 1709 Anterior Cervical Discectomy & Fusion - 5
## 1710 Anterior Cervical Discectomy & Fusion - 4
## 1711 Anterior Cervical Discectomy & Fusion - 3
## 1712 Anterior Cervical Discectomy & Fusion - 2
## 1713 Anterior Cervical Discectomy & Arthrodesis - 2
## 1714 Anterior Cervical Discectomy & Fusion
## 1715 Anterior Cervical Discectomy - 4
## 1716 Anterior Cervical Discectomy & Decompression - 1
## 1717 Anterior Cervical Discectomy & Fusion - 1
## 1718 Anterior Cervical Discectomy & Arthrodesis - 1
## 1719 Anterior Cervical Discectomy & Arthrodesis
## 1720 Anterior Cervical Discectomy & Decompression
## 1721 Anterior Cervical Discectomy - 3
## 1722 Anterior Cervical Discectomy - 2
## 1723 Anterior Cervical Discectomy
## 1724 Ankle Sprain - H&P
## 1725 Achilles Tendon Repair
## 1726 Anterior Cervical Discectomy - 1
## 1727 Ankle Pain - Consult
## 1728 Anterior Cervical Decompression
## 1729 AC Separation Revision & Hardware Removal
## 1730 Achilles Ruptured Tendon
## 1731 Achilles Lengthening
## transcription
## 1 PREOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1. Austin/Youngswick bunionectomy with Biopro implant.,2. Screw fixation, left foot.,HISTORY: , This 51-year-old male presents to ABCD General Hospital with the above chief complaint. The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time. The patient desires surgical treatment.,PROCEDURE IN DETAIL: , An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap. Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 7 cc of 0.5% Marcaine plain was injected in a Mayo-type block. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered to the operating table, the stockinet was reflected, and the foot was cleansed with wet and dry sponge.,Attention was then directed to the left first metatarsophalangeal joint. Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint, just medial to the extensor hallucis longus tendon. The incision was then deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was undermined medially, off of the joint capsule. A dorsal linear capsular incision was then made. Care was taken to identify and preserve the extensor hallucis longus tendon. The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx. There was noted to be a significant degenerative joint disease. There was little to no remaining healthy articular cartilage left on the head of the first metatarsal. There was significant osteophytic formation medially, dorsally, and laterally in the first metatarsal head as well as at the base of the proximal phalanx. A sagittal saw was then used to resect the base of the proximal phalanx. Care was taken to ensure that the resection was parallel to the nail. After the bone was removed in toto, the area was inspected and the flexor tendon was noted to be intact. The sagittal saw was then used to resect the osteophytic formation medially, dorsally, and laterally on the first metatarsal. The first metatarsal was then re-modelled and smoothed in a more rounded position with a reciprocating rasp. The sizers were then inserted for the Biopro implant. A large was noted to be of the best size. There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx. Following inspection, the sagittal saw was used to clean both the medial and lateral sides of the base. A small bar drill was then used to pre-drill for the Biopro sizer. The bone was noted to be significantly hardened. The sizer was placed and a large Biopro was deemed to be the correct size implant. The sizer was removed and bar drill was then again used to ream the medullary canal. The hand reamer with a Biopro set was then used to complete the process. The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit. There was noted to be distally increased range of motion after insertion of the implant.,Attention was then directed to the first metatarsal. A long dorsal arm Austin osteotomy was then created. A second osteotomy was then created just plantar and parallel to the first osteotomy site. The wedge was then removed in toto. The area was feathered to ensure high compression of the osteotomy site. The head was noted to be in a more plantar flexed position. The capital fragment was then temporarily fixated with two 0.45 K-wires. A 2.7 x 16 mm screw was then inserted in the standard AO fashion. A second more proximal 2.7 x 60 mm screw was also inserted in a standard AO fashion. With both screws, there was noted to be tight compression at the osteotomy sites.,The K-wires were removed and the areas were then smoothed with reciprocating rash. A screw driver was then used to check and ensure screw tightness. The area was then flushed with copious amounts of sterile saline. Subchondral drilling was performed with a 1.5 drill bit. The area was then flushed with copious amounts of sterile saline. Closure consisted of capsular closure with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl, followed by running subcuticular stitch of #5-0 Vicryl. Dressings consisted of Steri-Strips, Owen silk, 4x4s, Kling, Kerlix, and Coban. A total of 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected intraoperatively for further anesthesia. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well. The patient was transported to PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q. 4-6h. p.o. p.r.n. pain. The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema. The patient is to follow up with Dr. X in his office as directed.
## 2 PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane. The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1% Mydriacyl, and Iopidine was instilled. The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied. A total of
## 3 TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:, Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,HEMOSTASIS:, Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES: ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site. The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg. The right ankle tourniquet was then inflated. The right foot was prepped, scrubbed, and draped in normal sterile technique. Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe. The incision was deepened through the subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal. Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered. Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions. Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe. Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present. The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal. The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal. The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation. The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination. The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System. The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy. The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System. The 2 screws were inserted using AO technique. Upon insertion of the screws, the two wires were removed. Fixation of the osteotomy on the table was found to be excellent. The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction. The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation. The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues. Steri-Strips were used to approximate and reinforce the skin edges. At this time, the right ankle tourniquet was deflated. Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff. The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels. The patient was given instructions and education on how to continue caring for her right foot surgery at home. The patient was also given pain medication instructions on how to control her postoperative pain. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.
## 4 PREOPERATIVE DIAGNOSES,1. Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.,2. Diabetes.,3. Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES,1. Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.,2. Diabetes.,3. Peripheral vascular disease.,OPERATIONS,1. Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue.,2. Secondary closure of wound, complicated.,3. VAC insertion.,DESCRIPTION OF PROCEDURE:, After obtaining an informed consent, the patient was brought to the operating room where a general anesthetic was given. A time-out process was followed. All the staples holding the xenograft were removed as well as all the dressings and the area was prepped with Betadine soap and then painted with Betadine solution and draped in usual fashion.,The xenograft was not adhered at all and was easily removed. There was some, what appeared to be a seropurulent exudate at the bottom of the incision. This was towards the abdominal end, under the xenograft.,The graft was fully exposed and it was pulsatile. We then proceeded to use a pulse spray with bacitracin clindamycin solution to clean up the graft. A few areas of necrotic skin and subcutaneous tissue were debrided. Prior to this, samples were taken for aerobic and anaerobic cultures.,Normal saline 3000 cc was used for the irrigation and at the end of that the wound appeared much cleaner and we proceeded to insert the sponges to put a VAC system to it. There was a separate incision, which was bridged __________ to the incision of the abdomen, which we also put a sponge in it after irrigating it and we put the VAC in the main wound and we created a bridge to the second and more minor wound. Prior to that, I had inserted a number of Vesseloops through the edges of the skin and I proceeded to approximate those on top of the VAC sponge. Multiple layers were applied to seal the system, which was suctioned and appeared to be working satisfactorily.,The patient tolerated the procedure well and was sent to the ICU for recovery.
## 5 PREOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES: ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye. The patient has had a mild decrease in visual acuity, which has been a gradual change. The posterior capsule opacity was felt to be related to the decline in vision. The risks, benefits, and alternatives (including observation) were discussed. I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. Pupil was dilated per protocol. Patient was positioned at the YAG laser. Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis. A total of ** shots were used. Total energy was **. The patient tolerated the procedure well and there were no complications. The lens remained well centered and stable. Postoperative instructions were provided. Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg. Postoperative instructions were provided and the patient had no further questions.
## 6 TITLE OF OPERATION:, A complex closure and debridement of wound.,INDICATION FOR SURGERY:, The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain. There is no evidence of fevers. CRP was normal. Shunt CT were all normal. The thought was he has insidious fistula versus tract where recommendation was for excision of this tract.,PREOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,POSTOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,PROCEDURE DETAIL: , The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway, positioned supine and the right side was prepped and draped in the usual sterile fashion. Next, working on the fistula, this was elliptically excised. Once this was excised, this was followed down to the fistulous tract, which was completely removed. There was no CSF drainage. The catheter was visualized, although not adequately properly. Once this was excised, it was irrigated and then closed in multiple layers using 3-0 Vicryl for the deep layers and 4-0 Caprosyn and Indermil with a dry sterile dressing applied. The patient was reversed, extubated and transferred to the recovery room in stable condition. Multiple cultures were sent as well as the tracts sent to Pathology. All sponge and needle counts were correct.
## 7 PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg. I made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them. I then excised the ganglion and its stalk. In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve. We then identified the scapholunate ligament, which was uninjured. I irrigated and closed in layers and injected Marcaine with epinephrine. I dressed and splinted the wound. The patient was sent to the recovery room in good condition, having tolerated the procedure well.
## 8 TITLE OF OPERATION: , Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 2-month-old infant, born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt.,PREOP DIAGNOSIS: , Hydrocephalus.,POSTOP DIAGNOSIS: , Hydrocephalus.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of general endotracheal airway, positioned supine, head turned towards left. The right side prepped and draped in the usual sterile fashion. Next, using a 15 blade scalpel, two incisions were made, one in the parietooccipital region and. The second just lateral to the umbilicus. Once this was clear, the Bactiseal catheter was then tunneled. This was connected to a Strata valve. The Strata valve was programmed to a setting of 1.01 and this was ensured. The small burr hole was then created. The area was then coagulated. Once this was completed, new Bactiseal catheter was then inserted. It was connected to the Strata valve. There was good distal flow. The distal end was then inserted into the peritoneal region via trocar. Once this was insured, all the wounds were irrigated copiously and closed with 3-0 Vicryl and 4-0 Caprosyn as well as Indermil glue. The right frontal incision was then opened. The Ommaya reservoir identified and removed. The wound was then also closed with an inverted 3-0 Vicryl and 4-0 Caprosyn. Once all the wounds were completed, dry sterile dressings were applied. The patient was then transported back to the ICU in stable condition intubated. Blood loss minimal. All sponge and needle counts were correct.
## 9 DESCRIPTION OF PROCEDURE:, After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture.
## 10 DESCRIPTION OF PROCEDURE: , After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture.
## 11 VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified. General anesthesia was induced by the anesthesiologist. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. Hemostasis was maintained with wet-field cautery. Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant. A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. The MVR blade was used to make a sclerotomy between the preplaced sutures. An 8-0 nylon suture was then preplaced for a later sclerotomy closure. The infusion cannula was inspected and found to be in good working order. The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture. The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on. Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants.
## 12 PREOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye. CME, right eye.,POSTOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye. CME, right eye.,PROCEDURES: , Pars plana vitrectomy, membrane peel, 23-gauge, right eye.,PREOPERATIVE FINDINGS:, The patient had epiretinal membrane causing cystoid macular edema. Options were discussed with the patient stressing that the visual outcome was guarded. Especially since this membrane was of chronic duration there is no guarantee of visual outcome.,DESCRIPTION OF PROCEDURE: , The patient was wheeled to the OR table. Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified. Preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified. The fluid was run. Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock. Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ILM forceps, the membrane was peeled off in its entirety. There were no complications. DVT precautions were in place. I, as attending, was present in the entire case.
## 13 PREOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,OPERATION PERFORMED:, Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:, Local with IV sedation.,COMPLICATIONS:, None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Using AP and lateral fluoroscopic projections the T11 compression fracture was identified. Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the T11 pedicle on the left. The 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle. At this point using AP and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times. Once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body. At this point polymethylmethacrylate was mixed for 60 seconds. Once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body. It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra. A total 1.2 cc of cement was injected. On lateral view, the cement crushed to the right side as well. There was some dye infiltration into the disk space. There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,At this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space. Once the needle was withdrawn safely pressure was held over the site for three minutes. There were no complications. The patient was taken back to the recovery area in stable condition and kept flat for one hour. Should be followed up the next morning.
## 14 PROCEDURE PERFORMED:, Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:, Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment. It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:, The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length. Overall options and precautions of the pacemaker and indications were all discussed. They agreed to the pacemaker. The consent was signed and placed in the chart. The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure. Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given. Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty. A guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia. The skin was then undermined used to make a pocket for the pacemaker. The guidewire was then tunneled through the pacer pocket. Cordis sheath was then inserted through the guidewire. The guidewire and dilator were removed. ___ cordis sheath was in placed within. This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy. It was placed into the apex. Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle. The lead was then connected on pulse generator. The pocket was then irrigated and cleansed. Pulse generator and the wire was then inserted into the ____ pocket. The skin was then closed with gut suture. The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique. The area was then cleansed and dried. Steri-Strips and pressure dressing was then applied. The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name: Sigma, model #: 12345, serial #: 123456.,VENTRICLE LEAD:, Model #: 12345, the ventricular lead serial #: 123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:, Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8. The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS: ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well. There was no complications. The patient went to recovery in stable condition. Chest x-ray will be ordered. She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care. If you have any questions or concerns, please feel free to contact.
## 15 DESCRIPTION OF OPERATION:, The patient was brought to the operating room and appropriately identified. Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants. Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. The MVR blade was used to make a sclerotomy between the pre-placed sutures. An 8-0 nylon suture was then pre-placed for later sclerotomy closure. The infusion cannula was inspected and found to be in good working order. The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures. The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants. The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed. There was moderately severe vitreous hemorrhage, which was removed. Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades. These were dissected with curved scissors and judicious use of the vitrectomy cutter. There was some bleeding from the inferotemporal frond. This was managed by raising the intraocular pressure and using intraocular cautery. The surgical view became cloudy and the corneal epithelium was removed with a beaver blade. This improved the view. There is an area suspicious for retinal break near where the severe traction was inferotemporally. The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment. The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen. There was some residual hemorrhagic vitreous skirt seen. The soft-tip cannula was then used to perform an air-fluid exchange. Additional laser was placed around the suspicious area inferotemporally. The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut. A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye. The lid speculum was removed. Maxitrol ointment was instilled over the eye and the eye was patched. The patient was brought to the recovery room in stable condition.
## 16 PREOPERATIVE DIAGNOSIS: , Vitreous hemorrhage and retinal detachment, right eye.,POSTOPERATIVE DIAGNOSIS:, Vitreous hemorrhage and retinal detachment, right eye.,NAME OF PROCEDURE: , Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.,ANESTHESIA: , Local with standby.,PROCEDURE: ,The patient was brought to the operating room, and an equal mixture of Marcaine 0.5% and lidocaine 2% was injected in a retrobulbar fashion. As soon as satisfactory anesthesia and akinesia had been achieved, the patient was prepped and draped in the usual manner for sterile ophthalmic surgery. A wire lid speculum was inserted. Three modified sclerotomies were selected at 9, 10, and 1 o'clock. At the 9 o'clock position, the Accurus infusion line was put in place and tied with a preplaced #7-0 Vicryl suture. The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position, and closed vitrectomy was begun. Initially formed core vitrectomy was performed and formed anterior vitreous was removed. After this was completed, attention was placed in the posterior segment. Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted. These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata. After all the vitreous had been removed and the membranes released, the retina was completely mobilized. Total fluid-air exchange was carried out with complete settling of the retina. Endolaser was applied around the margins of the retinal tears, and altogether several 100 applications were placed in the periphery. Good reaction was achieved. The eye was inspected with an indirect ophthalmoscope. The retina was noted to be completely attached. The instruments were removed from the eye. The sclerotomy sites were closed with #7-0 Vicryl suture. The infusion line was removed from the eye and tied with a #7-0 Vicryl suture. The conjunctivae and Tenon's were closed with #6-0 plain gut suture. A collagen shield soaked with Tobrex placed over the surface of the globe, and a pressure bandage was put in place. The patient left the operating room in a good condition.
## 17 PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:, Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE: ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage. His condition is felt to be critical. In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy. I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic. Subsequently a 1 cm incision was made over Kocher's point. Hemostasis was obtained. Then a twist drill was made over this area. Bones strips were irrigated away. The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed. This was then passed into the left lateral ventricle on the first pass. Excellent aggressive very bloody CSF under pressure was noted. This stopped, slowed, and some clots were noted. This was irrigated and then CSF continued. Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well. The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.
## 18 PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia. A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position. An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided. Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen. A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities. Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly. Several minutes of compression was used for hemostasis. Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side. Also, an incision was made in the level of the knee and the saphenous vein was isolated there. The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis. Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us. Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg. The stab phlebectomies were performed with a hook and they were very satisfactory. Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL. The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.
## 19 PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS: ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:, Fertile male with completed family.,MEDICATIONS: ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS: ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy. I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed. He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table. Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely. The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin. The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath. The vas was brought out of the incision carefully. A 2-inch segment was isolated, and 1-inch segment was removed. The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side. The vas was grasped and brought up to the level of the skin. The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath. The vas was brought out of the incision carefully. A 2-inch segment was isolated, and 1-inch segment was removed. The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing. The patient was awakened and was returned to Recovery in satisfactory condition.
## 20 PREOPERATIVE DIAGNOSIS:, Desire for sterility.,POSTOPERATIVE DIAGNOSIS:, Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped. Then, 1% lidocaine was used for anesthesia. The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas. A segment about 3 cm in length was dissected out. It was clipped proximally and distally, and then the ends were cauterized after excising the segment. Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic. The identical procedure was performed on the contralateral side. He tolerated it well. He was discharged from the surgical center in good condition with Tylenol with Codeine for pain. He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead. Call if there are questions or problems prior to that time.
## 21 PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:, Aqueductal stenosis.,TITLE OF PROCEDURE: ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:, Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION: ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION: ,Triventricular hydrocephalus most consistent with aqueductal stenosis. The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral. The right frontal area was shaven and then the head was prepped and draped in a standard routine manner. The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine. A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture. Two Weitlaner were used to hold the scalp open. A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated. Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated. CSF was collected for routine studies. We saw the total absence of __________ consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle. I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening. The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________ various motions. We went through the membrane of Liliequist. We could see the basilar artery and the clivus, and there was no significant bleeding from the edges. The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture. The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips. The patient tolerated the procedure well.
## 22 PREOPERATIVE DIAGNOSES:, Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:, Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped. He was prepped with ChloraPrep and Betadine. Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000. He did receive antibiotics post procedure. He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion. A self-retaining retractor was placed. Burr hole was drilled with the cranial twist drill. The dura was punctured with a twist drill. A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle. The pressure was initially high. The CSF was clear and colorless. The CSF drainage rapidly tapered off because of the brain swelling. With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull. There was intermittent drainage of CSF after that. The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture. The patient tolerated the procedure well. No complications. Sponge and needle counts were correct. Blood loss is minimal. None replaced.
## 23 PREOPERATIVE DIAGNOSIS:, Vitreous hemorrhage, right eye.,POSTOPERATIVE DIAGNOSIS: , Vitreous hemorrhage, right eye.,PROCEDURE: ,Vitrectomy, right eye.,PROCEDURE IN DETAIL: ,The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia. Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus. MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture. Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed. All strands of significance were removed. Tractional detachment foci were apparent posteriorly along the temporal arcades. Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control. Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control. The intraocular pressure was within the normal range. The globe was irrigated with a topical antibiotic. The MVR incisions were closed with 7-0 Vicryl. No further manipulations were necessary. The conjunctiva was closed with 6-0 plain catgut. An eye patch was applied and the patient was sent to the recovery area in good condition.
## 24 DIAGNOSIS:, Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:, General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic. No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound. Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two. He tolerated the procedure well. A sterile dressing was applied. He was awakened and transferred to the recovery room in stable condition.
## 25 DESCRIPTION:, The patient was placed in the supine position and was prepped and draped in the usual manner. The left vas was grasped in between the fingers. The skin and vas were anesthetized with local anesthesia. The vas was grasped with an Allis clamp. Skin was incised and the vas deferens was regrasped with another Allis clamp. The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens. The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side. The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side. Dry sterile dressings were applied and the patient put on a scrotal supporter. The procedure was then terminated.
## 26 PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:, Bilateral vasectomy.,ANESTHESIA:, Local.,INDICATIONS FOR PROCEDURE: ,A gentleman who is here today requesting voluntary sterility. Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table. Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin. A small incision was made in the right hemiscrotum. The vas deferens was grasped with a vas clamp. Next, the vas deferens was skeletonized. It was clipped proximally and distally twice. The cut edges were fulgurated. Meticulous hemostasis was maintained. Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum. Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum. The vas deferens was isolated. It was skeletonized. It was clipped proximally and distally twice. The cut edges were fulgurated. Meticulous hemostasis was maintained. Then, 4-0 chromic was used to close the scrotal skin. A jockstrap and sterile dressing were applied at the end of the case. Sponge, needle, and instruments counts were correct.
## 27 PREOPERATIVE DIAGNOSES,1. Abnormal uterine bleeding.,2. Uterine fibroids.,POSTOPERATIVE DIAGNOSES,1. Abnormal uterine bleeding.,2. Uterine fibroids.,OPERATION PERFORMED: , Laparoscopic-assisted vaginal hysterectomy.,ANESTHESIA: , General endotracheal anesthesia.,DESCRIPTION OF PROCEDURE: ,After adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure. A speculum was placed into the vagina. A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix. The uterus was sounded to 10.5 cm. A #10 RUMI cannula was utilized and attached for uterine manipulation. The single-tooth tenaculum and speculum were removed from the vagina. At this time, the infraumbilical area was injected with 0.25% Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity. Aspiration was negative; therefore the abdomen was insufflated with carbon dioxide. After adequate insufflation, Veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity. Through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted. At this time, the suprapubic area was injected with 0.25% Marcaine with epinephrine. A 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation. Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular. The fallopian tubes have been previously interrupted surgically. The ovaries appeared normal bilaterally. The cul-de-sac was clean without evidence of endometriosis, scarring or adhesions. The ureters were noted to be deep in the pelvis. At this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty. The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery. The uterine artery was identified. It was doubly coagulated with bipolar electrocautery and transected. A similar procedure was carried out on the left with the left uterine cornu identified. The left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected. The remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery. The uterine artery was identified. It was doubly coagulated with bipolar electrocautery and transected. The anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection. At this time, attention was made to the vaginal hysterectomy. The laparoscope was removed and attention was made to the vaginal hysterectomy. The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum. A circumferential injection with 0.25% Marcaine with epinephrine was made at the cervicovaginal portio. A circumferential incision was then made at the cervicovaginal portio. The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty. The right uterosacral ligament was clamped, transected, and ligated with #0 Vicryl sutures. The left uterosacral ligament was clamped, transected, and ligated with #0 Vicryl suture. The parametrial tissue was then clamped bilaterally, transected, and ligated with #0 Vicryl suture bilaterally. The uterus was then removed and passed off the operative field. Laparotomy pack was placed into the pelvis. The pedicles were evaluated. There was no bleeding noted; therefore, the laparotomy pack was removed. The uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 Vicryl sutures. The vaginal cuff was then closed in a running fashion with #0 Vicryl suture. Hemostasis was noted throughout. At this time, the laparoscope was reinserted into the abdomen. The abdomen was reinsufflated. Evaluation revealed no further bleeding. Irrigation with sterile water was performed and again no bleeding was noted. The suprapubic trocar sheath was then removed under laparoscopic visualization. The laparoscope was removed. The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed. The skin incisions were closed with #4-0 Vicryl in subcuticular fashion. Neosporin and Band-Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition. Estimated blood loss was approximately 100 mL. There were no complications. The instrument, sponge, and needle counts were correct.
## 28 <NA>
## 29 PREOPERATIVE DIAGNOSES,1. A 40 weeks 6 days intrauterine pregnancy.,2. History of positive serology for HSV with no evidence of active lesions.,3. Non-reassuring fetal heart tones.,POST OPERATIVE DIAGNOSES,1. A 40 weeks 6 days intrauterine pregnancy.,2. History of positive serology for HSV with no evidence of active lesions.,3. Non-reassuring fetal heart tones.,PROCEDURES,1. Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2. Repair of the third-degree midline laceration lasting for 25 minutes.,ANESTHESIA: , Local.,ESTIMATED BLOOD LOSS: , 300 mL.,COMPLICATIONS: ,None.,FINDINGS,1. Live male infant with Apgars of 9 and 9.,2. Placenta delivered spontaneously intact with a three-vessel cord.,DISPOSITION: ,The patient and baby remain in the LDR in stable condition.,SUMMARY: , This is a 36-year-old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix. When she was admitted, her cervix was 2.5 cm dilated with 80% effacement. The baby had a -2 station. She had no regular contractions. Fetal heart tones were 120s and reactive. She was started on Pitocin for labor induction and labored quite rapidly. She had spontaneous rupture of membranes with a clear fluid. She had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural. With the rapid cervical change and descent of fetal head, there were some variable decelerations. The baby was at a +1 station when the patient began pushing. I had her push to get the baby to a +2 station. During pushing, the fetal heart tones were in the 80s and did not recover in between contractions. Because of this, I recommended a vacuum delivery for the baby. The patient agreed.,The baby's head was confirmed to be in the right occiput anterior presentation. The perineum was injected with 1% lidocaine. The bladder was drained. The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally. With the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station. The contraction ended. The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s. With the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station. A modified Ritgen maneuver was used to stabilize the fetal head. The vacuum was deflated and removed. The baby's head then delivered atraumatically. There was no nuchal cord. The baby's anterior shoulder delivered after a less than 30 second delay. No additional maneuvers were required to deliver the anterior shoulder. The posterior shoulder and remainder of the body delivered easily. The baby's mouth and nose were bulb suctioned. The cord was clamped x2 and cut. The infant was handed to the respiratory therapist.,Pitocin was added to the patient's IV fluids. The placenta delivered spontaneously, was intact and had a three-vessel cord. A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration. The right side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia. The third-degree laceration was also repaired with #3-0 Vicryl sutures. Local anesthesia was used. The capsule was visible, but did not appear to be injured at all. It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.,The patient tolerated the procedure very well. She remains in the LDR with the baby. The baby is vigorous, crying and moving all extremities. He will go to the new born nursery when ready. The total time for repair of the laceration was 25 minutes.
## 30 PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL: ,The patient was prepped and draped in the sterile fashion. An infraumbilical incision was formed and taken down to the fascia. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine. The skin was reattached to the fascia with 2-0 Vicryls. The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's. Patient was extubated and taken to the recovery area in stable condition.
## 31 PROCEDURE:, Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years. She comes in this morning with complaints of inability to swallow anything including her saliva. This started almost a day earlier. She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything. She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient. The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed. Daughter was also informed about the procedure and risks. Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg. The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus. There was a meat bolus in the distal esophagus. This was visualized after clearing the liquid material and small particles of what appeared to be carrots. The patient, however, was not tolerating the conscious sedation. Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation. Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net. Then, a snare was used to cut the meat bolus into pieces, as it was very soft. Small pieces were grabbed with the snare and pulled out. Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully. The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy. No active bleeding was seen. There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach. As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction. Treated as described above.,RECOMMENDATIONS:, IV Protonix 40 mg q.12h. Clear liquid diet for 24 hours. If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks. She should take Prevacid SoluTab 30 mg b.i.d. on discharge.
## 32 PREOPERATIVE DIAGNOSIS: , A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,POSTOPERATIVE DIAGNOSIS:, A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,PROCEDURE: , Exam under anesthesia with uterine suction curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,COMPLICATIONS:, None.,DRAINS:, None.,CONDITION:, Stable.,INDICATIONS: ,The patient is a 29-year-old gravida 5, para 1-0-3-1, with an LMP at 12/18/05. The patient was estimated to be approximately 10-1/2 weeks so long in her pregnancy. She began to have heavy vaginal bleeding and intense lower pelvic cramping. She was seen in the emergency room where she was found to be hemodynamically stable. On pelvic exam, her cervix was noted to be 1 to 2 cm dilated and approximately 90% effaced. There were bulging membranes protruding through the dilated cervix. These symptoms were consistent with the patient's prior experience of spontaneous miscarriages. These findings were reviewed with her and options for treatment discussed. She elected to proceed with an exam under anesthesia with uterine suction curettage. The risks and benefits of the surgery were discussed with her and knowing these, she gave informed consent.,PROCEDURE: ,The patient was taken to the operating room where she was placed in the seated position. A spinal anesthetic was successfully administered. She was then moved to a dorsal lithotomy position. She was prepped and draped in the usual fashion for the procedure. After adequate spinal level was confirmed, a bimanual exam was again performed. This revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size. The previously noted cervical exam was confirmed. The weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution. This solution was then removed approximately 10 minutes later with dry sterile gauze sponge. The anterior cervical lip was then attached with a ring clamp. The tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied. The tissue dislodged revealing fluid mixed with blood as well as an apparent 10-week fetus. The placental tissue was then gently tractioned out as well. A size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity. With the vacuum tubing applied in rotary motion, a moderate amount of tissue consistent with products of conception was evacuated. The sharp curette was then utilized to probe the endometrial surface. A small amount of additional tissue was then felt in the posterior uterine wall. This was curetted free. A second pass was then made with a vacuum curette. Again, the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered. A final pass was then made with a suction curette.,The ring clamp was then removed from the anterior cervical lip. There was only a small amount of bleeding following the curettage. The weighted speculum was then removed as well. The bimanual exam was repeated and good involution was noted. The patient was taken down from the dorsal lithotomy position. She was transferred to the recovery room in stable condition. The sponge and instrument count was performed and found to be correct. The specimen of products of conception and 10-week fetus were submitted to Pathology for further evaluation. The estimated blood loss for the procedure is less than 10 mL.
## 33 PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.,RESULTS,1. The left main was free of disease.,2. The left anterior descending and its branches were free of disease.,3. The circumflex was free of disease.,4. The right coronary artery was free of disease. There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,
## 34 PREOPERATIVE DIAGNOSIS:, Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS: ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1. Tonsillectomy.,2. Uvulopalatopharyngoplasty.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,PROCEDURE: , After all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained. The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity. Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots. Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole. The needle-tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar. Once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments. Once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,Attention was then directed over to the left tonsil in which a similar procedure was performed. Once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution. Now attention was directed to the posterior pillars. A hemostat was used to clamp the posterior pillar, which was then taken down with Metzenbaum scissors. The posterior pillar was then approximated to the anterior pillar with the use of #3-0 PDS suture so as to create a box shaped soft palate. Now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula. The mucosa was dissected off with the use of Potts scissors. Now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 PDS suture approximated with deep muscle layers. Now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 PDS sutures. Finally, #4-0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula, which had been reflected onto the soft palate. A final #3-0 PDS suture was used to further approximate the anterior and posterior tonsil pillars. Final inspection did not reveal any further bleeding. The mouth was then irrigated with saline and suctioned. At this point, the procedure was complete. He was awakened and taken to recovery room in stable condition. He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management. Of note, IV Decadron was administered during the procedure.
## 35 PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:, After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery. The sac was cleared of overlying adherent tissue, and the fascial defect was delineated. The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect. The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures. The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The skin was approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
## 36 PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:, Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office. Due to the severe cramping, a decision to undergo vacuum D&C was made. At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE: ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department. The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion. A weighted vaginal speculum was placed in the posterior vaginal vault. Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight. Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue. This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction. Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure. Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed. The patient was repositioned to supine position and taken to recovery room in stable condition.
## 37 PROCEDURE:, Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve. Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized. Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed. Meticulous hemostasis was maintained with bipolar electrocautery. The nerve was transposed anteriorly, superficial to the flexor-pronator mass. Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating. The subcutaneous tissue and skin were closed with simple interrupted sutures. Marcaine with epinephrine was injected into the wound. The elbow was dressed and splinted. The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.
## 38 PROCEDURE:, Upper endoscopy with foreign body removal.,PREOPERATIVE DIAGNOSIS (ES):, Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS (ES):, Penny in proximal esophagus.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was taken to the pediatric endoscopy suite. After appropriate sedation by the anesthesia staff and intubation, an upper endoscope was inserted into the mouth, over the tongue, into the esophagus, at which time the foreign body was encountered. It was grasped with a coin removal forcep and removed with an endoscope. At that time, the endoscope was reinserted, advanced to the level of the stomach and stomach was evaluated and was normal. The esophagus was normal with the exception of some mild erythema, where the coin had been sitting. There were no erosions. The stomach was decompressed of air and fluid. The scope was removed without difficulty.,SUMMARY:, The patient underwent endoscopic removal of esophageal foreign body.,PLAN:, To discharge home, follow up as needed.
## 39 PREOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA: ,Total IV general mask airway.,ESTIMATED BLOOD LOSS: ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia. The patient was placed on the operating table in supine position. After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction. After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma. A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents. A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep. Cortisporin Otic drops were placed followed by cotton balls. Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed. The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane. The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels. A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep. After this, the patient had Cortisporin Otic drops followed by cotton balls placed. The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well. The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.
## 40 PREOPERATIVE DIAGNOSIS: , Adenotonsillar hypertrophy and chronic otitis media.,POSTOPERATIVE DIAGNOSIS:, Adenotonsillar hypertrophy and chronic otitis media.,PROCEDURE PERFORMED:,1. Tympanostomy and tube placement.,2. Adenoidectomy.,ANESTHESIA: ,General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, prepped and draped in the usual fashion. After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,Attention was directed to the nasopharynx. With the Bovie set at 50 coag and the suction Bovie tip on the suction hose, the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior. The McIvor was relaxed and attention was then directed to the ears.,The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris.,An anteroinferior quadrant tympanostomy incision was made. Fluid was suctioned from the middle ear space, and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle. Cortisporin ear drops were instilled into the canal, and a cotton ball was placed in the external meatus.,By a similar procedure, the opposite tympanostomy and tube placement were accomplished.,The patient tolerated the procedure well and left the operating room in good condition.
## 41 PREOPERATIVE DIAGNOSIS: ,Bladder cancer.,POSTOPERATIVE DIAGNOSIS: , Bladder cancer.,OPERATION: ,Transurethral resection of the bladder tumor (TURBT), large.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is an 82-year-old male who presented to the hospital with renal insufficiency, syncopal episodes. The patient was stabilized from cardiac standpoint on a renal ultrasound. The patient was found to have a bladder mass. The patient does have a history of bladder cancer. Options were watchful waiting, resection of the bladder tumor were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE were discussed. The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.,DETAILS OF THE OR: ,The patient was brought to the OR, anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. A 23-French scope was inserted inside the urethra into the bladder. The entire bladder was visualized, which appeared to have a large tumor, lateral to the right ureteral opening.,There was a significant papillary superficial fluffiness around the left ________. There was a periureteral diverticulum, lateral to the left ureteral opening. There were moderate trabeculations throughout the bladder. There were no stones. Using a French cone tip catheter, bilateral pyelograms were obtained, which appeared normal. Subsequently, using 24-French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base. Deep biopsies were sent separately. Coagulation was performed around the periphery and at the base of the tumor. All the tumors were removed and sent for path analysis. There was an excellent hemostasis. The rest of the bladder appeared normal. There was no further evidence of tumor. At the end of the procedure, a 22 three-way catheter was placed, and the patient was brought to the recovery in a stable condition.
## 42 PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:, The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel. There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion. A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg. Perioperative antibiotics were infused. Time-out procedure was called. The medial epicondyle and the olecranon tip were well palpated. The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally. The ulnar nerve was identified proximally. It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply. The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches. The ulnar nerve was well-isolated before it entered the cubital tunnel. The arch of the FCU was well defined. The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization. Distally, the dissection was carried between the 2 heads of the FCU. Decompression of the nerve was performed between the heads of the FCU. The muscular branches were well protected. Similarly, the cutaneous branches in the arm and forearm were well protected. The venous plexus proximally and distally were well protected. The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it. Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected. Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended. There was no evidence of any subluxation. Satisfactory decompression was performed. Tourniquet was released. Hemostasis was achieved. Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples. A well-padded dressing was applied. The patient was then extubated and transferred to the recovery room in stable condition. There were no intraoperative complications noted. The patient tolerated the procedure very well.
## 43 PREOPERATIVE DIAGNOSIS:, Benign prostatic hyperplasia.,POSTOPERATIVE DIAGNOSIS:, Benign prostatic hyperplasia.,OPERATION PERFORMED: , Transurethral electrosurgical resection of the prostate.,ANESTHESIA: , General.,COMPLICATIONS:, None.,INDICATIONS FOR THE SURGERY:, This is a 77-year-old man with severe benign prostatic hyperplasia. He has had problem with urinary retention and bladder stones in the past. He will need to have transurethral resection of prostate to alleviate the above-mentioned problems. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Formation of urethral strictures.,PROCEDURE IN DETAIL: , The patient was identified, after which he was taken into the operating room. General LMA anesthesia was then administered. The patient was given prophylactic antibiotic in the preoperative holding area. The patient was then positioned, prepped and draped. Cystoscopy was then performed by using a #26-French continuous flow resectoscopic sheath and a visual obturator. The prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe. The anterior urethra was normal without strictures or lesions. The bladder was severely trabeculated with multiple bladder diverticula. There is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone. Using the ***** resection apparatus and a right angle resection loop, the prostate was resected initially at the area of the median lobe. Once the median lobe has completely resected, the left lateral lobe and then the right lateral lobes were taken down. Once an adequate channel had been achieved, the prostatic specimen was retrieved from the bladder by using an Ellik evacuator. A 3-mm bar electrode was then introduced into the prostate to achieve perfect hemostasis. The sheath was then removed under direct vision and a #24-French Foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained. The patient tolerated the operation well.
## 44 PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.
## 45 PROCEDURE: ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE: ,Under general anesthesia, the patient was prepped and draped in the usual manner. Manipulating probe placed on the cervix, changed gloves. Small cervical stab incision was made, Veress needle was inserted without problem. A 3 L of carbon dioxide was insufflated. The incision was enlarged. A 5-mm trocar placed through the incision without problem. Laparoscope placed through the trocar. Pelvic contents visualized. A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline. Under direct vision, the trocar was placed in the abdominal cavity. Uterus, tubes, and ovaries were all normal. There were no pelvic adhesions, no evidence of endometriosis. Uterus was anteverted and the right adnexa was placed on a stretch. The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation. The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated. The structure was confirmed to be tube by looking at fimbriated end. The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it. Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again. Tube was confirmed by fimbriated end. Gas was lend out of the abdomen. Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL. The patient went to the recovery room in good condition.
## 46 PREOPERATIVE DIAGNOSIS: ,1. Right cubital tunnel syndrome.,2. Right carpal tunnel syndrome.,3. Right olecranon bursitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Right cubital tunnel syndrome.,2. Right carpal tunnel syndrome.,3. Right olecranon bursitis.,PROCEDURES:, ,1. Right ulnar nerve transposition.,2. Right carpal tunnel release.,3. Right excision of olecranon bursa.,ANESTHESIA:, General.,BLOOD LOSS:, Minimal.,COMPLICATIONS:, None.,FINDINGS: , Thickened transverse carpal ligament and partially subluxed ulnar nerve.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, his right arm was sterilely prepped and draped in normal fashion. After elevation and exsanguination with an Esmarch, the tourniquet was inflated. The carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues. The palmar fascia was divided exposing the transverse carpal ligament, which was incised longitudinally. A Freer was then inserted beneath the ligament, and dissection was carried out proximally and distally.,After adequate release has been formed, the wound was irrigated and closed with nylon. The medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected. A medial antebrachial cutaneous nerve was identified and protected throughout the case. The ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed. The ulnar nerve was freed proximally and distally. The medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided. The intraarticular branch and the first branch to the SCU were transected; and then the nerve was transposed, it did not appear to have any significant tension or sharp turns. The fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight. The wound was irrigated. The tourniquet was deflated and the wound had excellent hemostasis. The subcutaneous tissues were closed with #2-0 Vicryl and the skin was closed with staples. Prior to the tourniquet being deflated, the subcutaneous dissection was carried out over to the olecranon bursa, where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa. A posterior splint was applied. Marcaine was injected into the incisions and the splint was reinforced with tape. He was awakened from the anesthesia and taken to recovery room in a stable condition. Final needle, instrument, and sponge counts were correct.
## 47 PREOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,POSTOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,OPERATIVE PROCEDURE:,1. Left canal wall down tympanomastoidectomy with ossicular chain reconstruction.,2. Microdissection.,3. NIM facial nerve monitoring for three hours.,COMPLICATIONS: ,None.,FINDINGS:, There is an extremely large canal cholesteatoma, which eroded most of the posterior and superior canal wall. There was a significant amount of myringosclerosis and tympanosclerosis. There is some mild erosion of the lenticular process of the incus. The facial nerve was normal. We removed the incus, removed the head of the malleus, and placed a titanium-PORP from the stapes capitulum to a cartilage graft.,PROCEDURE: , The patient was taken to the operating room, placed under general anesthetic and intubated without difficulty. The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure. There was no abnormal activity during this case. We inspected the ear canal, identified the huge defect, which was completely filled with cerumen. Through the ear canal, we removed as much as we could and then infiltrated the canal and postauricular area with 1:100,000 of epinephrine.,We prepped and draped the ear in a sterile fashion. We reopened the previously used postauricular incision and dissected down the mastoid cortex. We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone. A #6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out. We went all the way to the mastoid antrum. We finished a complete mastoidectomy with identification of the tegmen, sigmoid sinus. We removed the lateral aspect of the mastoid tip. We lowered the facial ridge. The incudostapedial joint was already membranous in nature, we went ahead and used the joint knife and removed the incus. We separated the incus from the stapes and then removed it. We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity.,There was no cholesteatoma within the middle ear space, but there was roughly 40% surface area perforation. The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic; this was removed. There was also a large focus of tympanosclerosis between the stapes crura, which was impinging the ability of the stapes to move. We carefully dissected this out. This did seem to improve the mobility of the stapes somewhat. At this point, there was a near total perforation. There was only a minimal amount of anterior remnant of the drum left. We tried to go ahead and harvest the temporalis fascia, but there was really only wisps of this fascia in place. He had already had a previous tympanoplasty, but even outside the areas where the graft was taken, the temporalis muscle was quite atrophied and lumpy, and I suspect this was due to his chronic disease and long history of corticosteroid usage. We harvested a few pieces as best as we could. We went ahead and did a meatoplasty by making a canal incision in the 6 o'clock and 12 o'clock positions. We excised cartilage posteriorly and inferiorly to enlarge the meatus. This cartilage was thin and used for cartilage tympanoplasty. We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it. We did cut a titanium-PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap. A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants. We placed a layer of Gelfoam lateral to the graft, closed the postauricular incision in layers and put 2 Merocel packs in the ear. Glasscock dressing was applied. The patient was awakened from anesthesia and taken to the recovery room in stable condition. He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week.
## 48 PREOPERATIVE DIAGNOSIS:, Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE: , Laparoscopic tubal ligation, Falope ring method.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 10 mL.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: ,A 35-year-old female, P4-0-0-4, who desires permanent sterilization. The risks of bleeding, infection, damage to other organs, and subsequent ectopic pregnancy was explained. Informed consent was obtained.,OPERATIVE FINDINGS: , Normal appearing uterus and adnexa bilaterally.,DESCRIPTION OF PROCEDURE: , After administration of general anesthesia, the patient was placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion. The speculum was placed in the vagina, the cervix was grasped with the tenaculum, and a uterine manipulator inserted. This area was then draped off the remainder of the operative field.,A 5-mm incision was made umbilically after injecting 0.25% Marcaine, 2 mL. A Veress needle was inserted to confirm an opening pressure of 2 mmHg. Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity. The Veress needle was removed, and a 5-mm port placed. Position was confirmed using a laparoscope. A second port was placed under direct visualization, 3 fingerbreadths suprapubically, 7 mm in diameter, after 2 mL of 0.25% Marcaine was injected. This was done under direct visualization. The pelvic cavity was examined with the findings as noted above. The Falope rings were then applied to each tube bilaterally. Good segments were noted to be ligated. The accessory port was removed. The abdomen was deflated. The laparoscope and sheath was removed. The skin edges were approximated with 5-0 Monocryl suture in subcuticular fashion. The instruments were removed from the vagina. The patient was returned to the supine position, recalled from anesthesia, and transferred to the recovery room in satisfactory condition. Sponge and needle counts correct at the conclusion of the case. Estimated blood loss was minimal.
## 49 PREOPERATIVE DIAGNOSIS: ,Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,POSTOPERATIVE DIAGNOSIS: , Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,TITLE OF OPERATION: , Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 59-year-old white male, who had an initial occurrence of a transitional cell carcinoma 5 years back. He was found to have a new tumor last fall, and cystoscopy in November showed Ta papillary-appearing lesion inside the bladder neck anteriorly. The patient had coronary artery disease and required revascularization, which occurred at the end of December prior to the tumor resection. He is fully recovered and cleared by Cardiology and taken to the operating room at this time for TURBT.,FINDINGS: , Cystoscopy of the anterior and posterior urethra was within normal limits. From 12 o'clock to 4 o'clock inside the bladder neck, there was a papillary tumor with some associated blood clot. This was completely resected. There was an abnormal dysplastic area in the left lateral wall that was biopsied, and the remainder of the bladder mucosa appeared normal. The ureteral orifices were in the orthotopic location. Prostate was 15 g and benign on rectal examination, and there was no induration of the bladder.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite, and after adequate general laryngeal mask anesthesia obtained, placed in the dorsal lithotomy position and his perineum and genitalia were sterilely prepped and draped in usual fashion. He had been given oral ciprofloxacin for prophylaxis. Rectal bimanual examination was performed with the findings described. Cystourethroscopy was performed with a #23-French ACMI panendoscope and 70-degree lens with the findings described. A barbotage urine was obtained for cytology. The cystoscope was removed and a #24-French continuous flow resectoscope sheath was introduced over visual obturator and cold cup biopsy forceps introduced. Several biopsies were taken from the tumor and sent to the tumor bank. I then introduced the Iglesias resectoscope element and resected all the exophytic tumor and the lamina propria. Because of the Ta appearance, I did not intentionally dissect deeper into the muscle. Complete hemostasis was obtained. All the chips were removed with an Ellik evacuator. Using the cold cup biopsy forceps, biopsy was taken from the dysplastic area in the left bladder and hemostasis achieved. The irrigant was clear. At the conclusion of the procedure, the resectoscope was removed and a #24-French Foley catheter was placed for efflux of clear irrigant. The patient was then returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.
## 50 PREOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:, Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS: ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion. The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine. Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion. Hemostasis was controlled with pressure. The patient tolerated the procedure well, pending the results of biopsy.
## 51 PREOPERATIVE DIAGNOSIS:, Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE:,1. Nerve root decompression at L45 on the left side.,2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3. Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity. MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels. After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus. The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture. The #18-gauge needle was inserted off of midline. A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed. Negative aspiration was carefully performed. Omnipaque 240 dye was then injected through the #16-gauge RK needle. The classical run off was noted. A filling defect was noted @ L45 nerve root on the left side. After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle. Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance. As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized. The tip of the catheter was noted to be @ L45 level on the left side. After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side. After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape. The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected. The classical run off was noted in the lumbar region. Some lyses of adhesions were also visualized at this time with barbotage technique. Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted. Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect. After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose. Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.) The catheter was then capped with a bacterial filter. The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed. A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure. This verified positive nerve root decompression. The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side. Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted. This patient did not report any problems and reported pain reduction.
## 52 PREOPERATIVE DIAGNOSES:, Multiparity requested sterilization and upper abdominal wall skin mass., ,POSTOPERATIVE DIAGNOSES: ,Multiparity requested sterilization and upper abdominal wall skin mass.,OPERATION PERFORMED: , Postpartum tubal ligation and removal of upper abdominal skin wall mass.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,DRAINS: , None.,ANESTHESIA: , Spinal.,INDICATION: , This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007. The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,PROCEDURE IN DETAIL:, The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department. The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation. Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision. The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed. The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection. Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end. A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized. Adequate hemostasis was noted. This tube was placed back in its anatomic position. The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position. The peritoneum as well as fascia was reapproximated with 0-Vicryl. The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch. Pressure dressings were applied. Marcaine 10 mL was used prior to making an incision. Sterile dressing was applied. The large mole-like lesion was grasped with Allis. It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied. Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.
## 53 A 1 cm infraumbilical skin incision was made. Through this a Veress needle was inserted into the abdominal cavity. The abdomen was filled with approximately 2 liters of CO2 gas. The Veress needle was withdrawn. A trocar sleeve was placed through the incision into the abdominal cavity. The trocar was withdrawn and replaced with the laparoscope. A 1 cm suprapubic skin incision was made. Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope. The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis. Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal. The probe was withdrawn and replaced with the bipolar cautery instrument. The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus. Electrical current was applied to the tube at this point and fulgurated. The tube was then regrasped just distal to this and refulgurated. It was then regrasped just distal to the lateral point and refulgurated again. The same procedure was then carried out on the opposite tube. The bipolar cautery instrument was withdrawn and replaced with the probe. The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes. The upper abdomen was visualized, and the liver surface was normal. The gas was allowed to escape from the abdomen, and the instruments were removed. The skin incisions were repaired. The instruments were removed from the vagina.,There were no complications to the procedure. Blood loss was minimal. The patient went to the postanesthesia recovery room in stable condition.
## 54 DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:, None.,FINDINGS: ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position. After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined. She was found to have an anteverted uterus and no adnexal mass. She was prepped and draped in the usual fashion. The Foley catheter was placed. A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife. A Veress needle was inserted into the abdomen. Intraperitoneal location was verified with approximately 10 cc of sterile solution. A pneumoperitoneum was created. The Veress needle was then removed, and a trocar was inserted directly without difficulty. Intraperitoneal location was verified visually with the laparoscope. There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization. An attempt was made to close the fascia with a figure-of-eight suture. However, this was felt to be more subcutaneous. The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.
## 55 PREOPERATIVE DIAGNOSES,1. Bowel obstruction.,2. Central line fell off.,POSTOPERATIVE DIAGNOSES,1. Bowel obstruction.,2. Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction. She was being fed through a central line, which as per the patient was just put yesterday and this slipped out. At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty. A Seldinger technique was used and a triple-lumen catheter was inserted. There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.
## 56 PREOPERATIVE DIAGNOSIS: ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:, Right trigger thumb.,OPERATIONS PERFORMED:, Trigger thumb release.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:,
## 57 PREOPERATIVE DIAGNOSIS: , Foraminal disc herniation of left L3-L4.,POSTOPERATIVE DIAGNOSES:,1. Foraminal disc herniation of left L3-L4.,2. Enlarged dorsal root ganglia of the left L3 nerve root.,PROCEDURE PERFORMED:, Transpedicular decompression of the left L3-L4 with discectomy.,ANESTHESIA:, General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,HISTORY: , This is a 55-year-old female with a four-month history of left thigh pain. An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root, which appears to be a foraminal disc herniation effacing the L3 nerve root. Upon exploration of the nerve root, it appears that there was a small disc herniation in the foramen, but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally. There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body, so otherwise the surrounding anatomy is normal. I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root. But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer, at this point I was not able to perform this biopsy without prior consent from the patient. So, surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations.,OPERATIVE PROCEDURE: , The patient was taken to OR #5 at ABCD General Hospital in a gurney. Department of Anesthesia administered general anesthetic. Endotracheal intubation followed. The patient received the Foley catheter. She was then placed in a prone position on a Jackson table. Bony prominences were well padded. Localizing x-rays were obtained at this time and the back was prepped and draped in the usual sterile fashion. A midline incision was made over the L3-L4 disc space taking through subcutaneous tissues sharply, dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3. Retractors were placed into the wound to retract the musculature. At this point, the pars interarticularis was identified and the facet joint of L2-L3 was identified. A marker was placed over the pedicle of L3 and confirmed radiographically. Next, a microscope was brought onto the field. The remainder of the procedure was noted with microscopic visualization. A high-speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis. At this point, soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen. As the disc space of L3-L4 is identified, there is a small prominence of the disc, but not as impressive as I would expect on the MRI. A discectomy was performed at this time removing only small portions of the lateral aspect of the disc. Next, the nerve root was clearly dissected out and visualized, the lateral aspect of the nerve root appears to be normal in structural appearance. The medial aspect with the axilla of the nerve root appears to be enlarged. The color of the tissue was consistent with a nerve root tissue. There was no identifiable plane and this is a gentle enlargement of the nerve root. There are no circumscribed lesions or masses that can easily be separated from the nerve root. As I described in the initial paragraph, since I was not prepared to perform a biopsy on the nerve and the patient had not been consented, I do not think it is reasonable to take the patient to this procedure, because she will have persistent weakness and pain in the leg following this procedure. So, at this point there is no further decompression. A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral. The pedicle was palpated inferiorly and medially and there was no compression, as the nerve root can be easily moved medially. The wound was then irrigated copiously and suctioned dry. A concoction of Duramorph and ______ was then placed over the nerve root for pain control. The retractors were removed at this point. The fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissues with #2 Vicryl sutures, and Steri-Strips covering the incision. The patient transferred to the hospital gurney, extubated by Anesthesia, and subsequently transferred to Postanesthesia Care Unit in stable condition.
## 58 PREOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,PROCEDURE PERFORMED:,1. Insertion of a right brachial artery arterial catheter.,2. Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:, Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis. She was severely dehydrated and necessitated some fluid boluses. The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic. She required intubation and has been ventilator-dependent in the Intensive Care since that time. The patient developed very high temperatures as well as leukocytosis. Her lines required being changed.,PROCEDURE:,1. RIGHT BRACHIAL ARTERIAL LINE: ,The patient's right arm was prepped and draped in the usual sterile fashion. There was a good brachial pulse palpated. The artery was cannulated with the provided needle and the kit. There was good arterial blood return noted immediately. On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty. The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery. The femoral catheter was used in this case secondary to the patient's severe edema and anasarca. We did not feel that the shorter catheter would provide enough length. The catheter was connected to the system and flushed without difficulty. A good waveform was noted. The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2. RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER: ,The patient was prepped and draped in the usual sterile fashion. 1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle. Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized. Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle. We roughed the needle down off the clavicle and directed it towards the sternal notch. There was good venous return noted immediately. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein. The needle was then removed. A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein. Next, the triple lumen catheter was inserted over the guidewire without difficulty. The guidewire was removed. All the ports aspirated and flushed without difficulty. The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied. The patient tolerated the above procedures well. A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.
## 59 PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED: ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:, The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site. The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:, The patient's legal guardian was talked to. All questions were answered and consent was obtained. The patient was sterilely prepped and draped. Approximately 4 cc of 1% lidocaine was injected into the inguinal site. A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated. A guidewire was then placed through the needle. The needle was then removed. The skin was ________ at the base of the wire and a dilator was placed over the wire. The triple lumen catheters were then flushed with bacteriostatic saline. The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed. Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports. Each port was closed off and also kept off. Straight needle suture was then used to suture the triple lumen catheter down to the skin. Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site. The surgical site was then sterilely cleaned. The patient tolerated the full procedure well. There were no complications. The nurse was then contacted to allow for access of the triple lumen catheter.
## 60 PROCEDURE: , Trigger finger release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease. Meticulous hemostasis was maintained with bipolar electrocautery.,The tendons were identified and atraumatically pulled to ensure that no triggering remained. The patient then actively moved the digit, and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.
## 61 PROCEDURE: ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx. Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained. The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.
## 62 INDICATIONS FOR PROCEDURE:, Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:, Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance. The probe was placed so that the larger diameter was in the anterior-posterior position during insertion. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. At the end, it was removed without trauma and there was no blood tingeing. It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned. There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:, Both groins were prepped and draped. The patient was placed at 10 degrees head-up position. A Cook 4-French double-lumen 8-cm catheter kit was opened. Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin. There were several successful punctures of these vessels, but I was unable to advance Seldinger wire. After removal of the needles, the area was compressed digitally for approximately 5 minutes. There was a small hematoma that was not growing. Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds. Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath. Further observation, the capillary refill and circulation of the left leg became more than adequate. The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end. At the end of the procedure, the circulation of the leg was intact.,
## 63 PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley catheter, 30 mL balloon.,ESTIMATED BLOOD LOSS:, Minimal.,INDICATIONS FOR PROCEDURE: , This is a 74-year-old male who presented with microscopic and an episode of gross hematuria. He underwent an IVP, which demonstrated enlarged prostate and normal upper tracts. Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor. He is brought to the operating room for transurethral resection of that bladder tumor.,DESCRIPTION OF OPERATION: , After preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic. He was placed in lithotomy position and prepped and draped in the usual fashion. Using the visual obturator, the resectoscope was then inserted per urethra into the bladder. The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice. Using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion. Following completion of resection down to the base, the bladder was _______ free of tumor specimen. The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen. Hemostasis was assured with electrocautery. The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor. Following completion of the fulguration, there was good hemostasis. The remainder of the bladder was without evidence of significant abnormality. Both ureteral orifices were visualized and noted to drain freely of clear urine. The bladder was filled and the resectoscope was removed. A 22-French 3-way Foley catheter was inserted per urethra into the bladder. The balloon was inflated to 30 mL. The catheter with sterile continuous irrigation and was noted to drain clear irrigant. The patient was then removed from lithotomy position. He was in stable condition.
## 64 PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS: ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA: ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube. The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined. The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring. The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000. A #67 blade was used to perform the incision. Electrocautery was used to remove excess fat tissue to expose the strap muscles. The strap muscles were grasped and divided in the midline with a cutting electrocautery. Sharp dissection was used to expose the anterior trachea and cricoid cartilage. The thyroid isthmus was identified crossing just below the cricoid cartilage. This was divided in the midline with electrocautery. Blunt dissection was used to expose adequate cartilaginous rings. A 4.0 silk was used for stay sutures to the midline of the cricoid. Additional stay sutures were placed on each side of the third tracheal ring. Thin DuoDerm was placed around the stoma. The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings. The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl. A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties. A flexible scope was passed through the tracheotomy tube. The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube. Ventilation was confirmed. There was good chest rise and no appreciable leak. The procedure was terminated. The patient was in stable condition. Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.
## 65 PREOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Trabeculectomy with mitomycin C, XXX eye 0.3 c per mg times three minutes.,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox, Ocular, and pilocarpine. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position. A Lieberman lid speculum was used to provide exposure. Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly. This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap. Residual episcleral vessels were cauterized with Eraser-tip cautery. Sponges soaked in mitomycin C 0.3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock. Sponges were removed and area was copiously irrigated with balanced salt solution. A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap. This was dissected anteriorly with a crescent blade to clear cornea. A temporal paracentesis was then made. Scleral flap was lifted and a Super blade was used to enter the anterior chamber. A Kelly-Descemet punch was used to remove a block of limbal tissue. DeWecker scissors were used to perform a surgical iridectomy. The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea. A scleral flap was then re- approximated back on the bed. One end of the scleral flap was closed with a #10-0 nylon suture in interrupted fashion and the knot was buried. The other end of the scleral flap was closed with #10-0 nylon suture in interrupted fashion and the knot was buried. The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber. Therefore it was felt that another #10-0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed. The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber. Conjunctiva was then re-approximated to the limbus and closed with #9-0 Vicryl suture on a TG needle at each of the peritomy ends. Then a horizontal mattress style #9-0 Vicryl suture was placed at the center of the conjunctival peritomy. The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck- cel sponge. The anterior chamber was inflated and there was noted that the superior bleb was well formed. At the end of the case, the pupil was round, the chamber was formed and the pressure was felt to be adequate. Speculum and drapes were carefully removed. Ocuflox and Maxitrol ointment were placed over the eye. Atropine was also placed over the eye. Then an eye patch and eye shield were placed over the eye. The patient was taken to the recovery room in good condition. There were no complications.
## 66 PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,PROCEDURES PERFORMED:,1. Tracheostomy.,2. Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:, The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes. He had required ventilator assistance and was transported to the ICU setting. Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained. The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube. The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker. The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution. The patient was prepped and draped in usual fashion. The surgeons were gowned and gloved. A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage. Blunt dissection was then carried down until the fascia overlying the strap muscles were identified. At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery. Once the strap muscles have been identified, palpation was performed to identify any arterial aberration. A high-riding innominate was not identified. At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized. Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery. Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion. This cleared a significant portion of the trachea. The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery. Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea. The second tracheal ring was identified. The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based. At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff. The airway was entered and inferior to the base, window was created. The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified. At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen. The balloon was inflated and the ventilator was attached. He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist. Now, all surgical retractors were removed. The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture. The tube was further secured around the patient's neck with IV tubing. Finally, a drain sponge was placed. At this point, procedure was felt to be complete. The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.
## 67 PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF. The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed. The patient was noted at that time to have transglottic edema. Biopsies were taken. At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection. The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support. A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit. The patient was placed in a supine position. The neck was then extended. The sutures that were previously in place in the #6 Shiley with proximal extension were removed. The patient was preoxygenated to 100%. After several minutes, the patient was noted to have a pulse oximetry of 100%. The IV tubing that was supporting the patient's trache was then cut. The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire. The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned. With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea. The guidewire was then removed and the inner cannula was then placed into the tracheostomy. The patient was then reconnected to the ventilator and was noted to have normal tidal volumes. The patient had a tidal volume of 500 and was returning 500 cc to 510 cc. The patient continued to saturate well with saturations 99%. The patient appeared comfortable and her vital signs were stable. A soft trache collar was then connected to the trachesotomy. A drain sponge was then inserted underneath the new trache site. The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well. 0.25% acetic acid soaks were ordered to the drain sponge every shift.
## 68 PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement. However developed progressive problems and he had two additional stents placed with some initial improvement. Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY. He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes. The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management. Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient. Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length. The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position. Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion. The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine. A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out. The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly. Strap muscles were separated in the midline, dissection carried down to visceral fascia. Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks. There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable. There was a markedly enlarged thyroid isthmus. Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection. Trachea was exposed from the cricoid to the fourth ring which entered down into the chest. The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation. The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness. The trachea was entered and visualized with thickening of the mucosa and submucosa was noted. The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered. Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site. Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea. A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis. After removal of the stents and granulation tissue, the upper trachea was widely patent. The mid trachea had some marked narrowing secondary to granulation. Stent material was removed from this area as well. In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time. All visible stent material in the upper and mid trachea were removed. Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third. Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube. A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa. The distal trachea and mainstem bronchi were widely patent. This secured his airway and no further manipulation felt to be needed at this time. Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl. The skin laterally to the trach site was closed with running 2-0 Prolene. Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition. The patient tolerated the procedure well without complication.
## 69 PREOPERATIVE DIAGNOSIS: ,Thyroid goiter with substernal extension on the left.,POSTOPERATIVE DIAGNOSIS:, Thyroid goiter with substernal extension on the left.,PROCEDURE PERFORMED:, Total thyroidectomy with removal of substernal extension on the left.,THIRD ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 200 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 54-year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine. The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch. The patient was then immediately set up for surgery. After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position. The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed. After this, the patient then had the area marked initially. The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total. After this, the patient was then prepped and draped in the usual sterile fashion. A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline. After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle. There appeared to be a natural dehiscence of the platysma in the midline. A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps. Any bleeding was controlled with monopolar cauterization. After this, the two anterior large jugular veins were noted and resected laterally. The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right. This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors. After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles. The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland. After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners. The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly. After this, the superior and inferior parathyroid glands were noted. The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly. After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie. The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors. After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly. The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat. Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly. The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament. The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally. The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology. The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region. This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture. The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl. The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top. After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed. The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain. The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition. The patient tolerated the procedure well and remained stable throughout.
## 70 PREOPERATIVE DIAGNOSIS:, Left thyroid mass.,POSTOPERATIVE DIAGNOSIS:, Left thyroid mass.,PROCEDURE PERFORMED:, Left total thyroid lumpectomy.,ANESTHESIA,: General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE:, The patient is a 76-year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole. The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,PROCEDURE: ,The patient is brought to the operative suite by Anesthesia. The patient was placed on the operative table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll. After this, the skin incision was marked approximately two fingerbreadths above the sternal notch. It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision. The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions. After this, the midline was then identified and grasped on either side with a DeBakey forceps. The raphe was noted and Bovie cauterization was utilized to cut down into this region. The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle. It was separated on the left side from the patient's sternothyroid muscle. After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors. Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners. After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified. The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself. It was freed from the thyroid gland and reflected laterally and posteriorly. The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally. After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally. The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter. As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed. The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected. After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole. The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein. Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors. The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea. Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito. After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie. The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. Surgicel was then cut in small strips and three replaced in the lateral part of the neck.,The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses. The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut. Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing. The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition. The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.
## 71 PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:, The patient was bought to the operating room and placed in the supine position. After induction of anesthesia, a tourniquet was placed on the upper thigh. Sterile prepping and draping proceeded. The tourniquet was inflated to 300 mmHg. A midline incision was made, centered over the patella. Dissection was sharply carried down through the subcutaneous tissues. A median parapatellar arthrotomy was performed. The lateral patellar retinacular ligaments were released and the patella was retracted laterally. Proximal medial tibia was denuded, with mild release of medial soft tissues. The ACL and PCL were released. The medial and lateral menisci and suprapatellar fat pad were removed. These releases allowed for anterior subluxation of tibia. An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia. Its alignment was checked with the rod and found to be adequate. The tibia was then allowed to relocate under the femur.,An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques. An anterior rough cut was made. The distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed. The distal cut was performed.,A spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment. Femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made. The notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made. The trial femoral component was impacted onto the distal femur and found to have an excellent fit. A trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes. Appropriate rotation of the tibial component was identified and marked. The trials were removed and the tibia was brought forward again. The tibial plate size was checked and the plate was pinned to plateau. A keel guide was placed and the keel was then made. The femoral intramedullary hole was plugged with bone from the tibia. The trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,The patella was held in a slightly everted position with knee in extension. Patellar width was checked with calipers. A free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers. Sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy. Any excess lateral patellar bone was recessed. The trial patellar component was placed and found to have adequate tracking. The trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried. The cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted. The excess cement was removed from the gutters and anterior and posterior parts of the knee. The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened. Once the cement had hardened, the tourniquet was deflated. The knee was dislocated again, and any excess cement was removed with an osteotome. Thorough irrigation and hemostasis were performed. The real polyethylene component was placed and pinned. Further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed. The arthrotomy was closed using 0 Ethibond and Vicryl sutures. The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures. The skin was sealed with staples. Xeroform and a sterile dressing were applied followed by a cold-pack and Ace wrap. The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.
## 72 PREOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Negligible.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines. In the preoperative area, the patient received pilocarpine drops. The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain. Approximately 3 mL were given. The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye. During the draping process, care was taken to isolate the lashes. A screw type speculum was inserted to maintain patency of lids. A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva. A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea. All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis. A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade. This was approximately one-half scleral depth in thickness. A crescent blade was then used to dissect forward the clear cornea. Hemostasis was again achieved with wet-field cautery. A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes. The site was then profusely irrigated with balanced salt solution. A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed. A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed. Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps. The iris was then repositioned into the eye and the anterior chamber was inflated with BSS. The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried. The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle. BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage. Antibiotic and steroid drops were placed in the eye as was homatropine 5%. The antibiotic consisted of Vigamox and the steroid was Econopred Plus. A patch and shield were placed over the eye after the drape was removed. The patient was taken to the recovery room in good condition. She will be seen in followup in the office tomorrow.
## 73 PREOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1. Tracheostomy with skin flaps.,2. SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home. The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:, The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position. After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg. The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch. The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck. After this, the patient was then prepped and draped with Hibiclens. A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion. After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties. Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles. The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified. Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps. The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed. The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus. Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization. After this, the patient's anterior trachea was then identified and cleaned with pusher. After this, the cricoid cartilage along the first and second tracheal rings was identified. The cricoid hook was placed and the trachea was brought more anteriorly and superiorly. After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker. After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage. After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap. After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%. The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition. The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours. The patient will have the stent guidewire removed with a scoop catheter 11 cm placed.
## 74 PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of Ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg.,A straight anterior incision was carried down through the skin and subcutaneous tissue. Unilateral flaps were developed and a median retinacular parapatellar incision was made. The extensor mechanism was partially divided and the patella was everted. Some of the femoral bone spurs were resected using an osteotome and a rongeur. Ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,At this point the ACL was resected. Some of the fat pad and synovium were resected, as well as both medial and lateral menisci. A posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. The intramedullary guide was used for cutting the tibia. It was set at 8 mm. An additional 2 mm was resected because of a moderate defect medially.,A trial reduction was done with a 71 tibial baseplate. This was pinned and drilled and then trial reduction done with a 10-mm insert.,This gave good stability and a full range of motion.,The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. A 34-mm component was drilled for.,A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. A packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. The tibia baseplate was secured and the patella was inserted, held with a clamp. The extraneous cement was removed. At this point the tibial baseplate was locked into place and the femoral component also seated solidly.,The knee was extended, held in this position for another 5-6 minutes until the cement was cured. Further extraneous cement was removed. The pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,Retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 Vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. A sterile, bulky compression dressing was placed. The patient was stable on operative release.
## 75 PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03. The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X.,TOURNIQUET TIME: , 76 minutes.,BLOOD LOSS: , 150 cc.,ANESTHESIA: ,General.,IMPLANT USED FOR PROCEDURE:, NexGen size F femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component. The patella on the left was not resurfaced.,GROSS INTRAOPERATIVE FINDINGS: , Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau. The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,HISTORY: ,This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living. He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc. This has only provided him with temporary relief. It is for that reason, he is elected to undergo the above-named procedure.,All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain. He has agreed to undergo this procedure and a consent was obtained preoperatively.,PROCEDURE: , The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table. At this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated. An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure. The tourniquet was then inflated to 325 mmHg. At this time, a standard midline incision was made towards the total knee. We did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus. We did start off with a small midline skin incision in case we were going to do a unicompartmental. Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement. It is for this reason that we extended the incision and underwent with the total knee replacement. Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella. Once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide. A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee. At this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur. At this time, the intramedullary guide was then inserted and placed in three degrees of external rotation. Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues. Next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus. This was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed. At this time, the intramedullary guide was removed and a final cutting block was placed. This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking. At this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues. An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut. Peg holes were then drilled.,The block was then removed and an osteotome was then used to remove all the bony cut pieces. At this time with a better exposure of the proximal tibia, we placed external tibial guide. This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia. At this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy. Prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection. At this time, a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments. Once this was removed, we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface. The knee was taken through range of motion and revealed excellent femorotibial articulation. The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release. Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis. At this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut. At this time, the prosthesis was removed. A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia. Once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components. At this time, polymethyl methacrylate cement was then mixed. The cement was placed on the tibial surface as well as the underneath surface of the component. The component was then placed and impacted with excess cement removed. In a similar fashion, the femoral component was also placed. A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content. Once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone. Once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry. The knee was again taken through range of motion with a 12 mm plastic as well as #14. The #14 appeared to be a bit too tight especially in extremes of flexion. We decided to go with a #12 mm polyethylene tray. At this time, this was placed to the tibial articulation and then left in place. This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia. The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact. A drain was placed and cut to length.,At this time, the knee was irrigated and copiously suction dried. #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion. A tight capsular closure was performed. This was reinforced with a #1-0 running Vicryl suture. At this time, the knee was again taken through range of motion to assure tight capsular closure. At this time, copious irrigation was used to irrigate the superficial wound. #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture. The skin was then approximated with staples. The leg was then cleansed. Sterile dressing consisting of Adaptic, 4x4, ABDs, and Kerlix roll were then applied. At this time, the patient was extubated and transferred to recovery in stable condition. Prognosis is good for this patient.
## 76 PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: Approximately 66 minutes.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,COMPONENTS: , A NexGen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a NexGen cruciate retaining size E femoral component, and a size 38 9.5 mm thickness All-Poly Patella.,BRIEF HISTORY:, The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs. She wishes to proceed with arthroplasty at this time.,PROCEDURE: ,The patient was taken to the Operative Suite at ABCD General Hospital on 09/11/03. She was placed on the operating table. Department of Anesthesia administered a spinal anesthetic. Once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion. An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh. A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum. A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle. Care was then ensured that the patellar tendon was not violated. The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line. Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia. The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed. Rongeur was used to take out any osteophytes and the size of approximately size E. At this point, the epicondyle axis guide was then inserted and aligned in a proper orientation. The anterior cutting guide was then placed. Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur. After this was performed, this was removed and the distal femoral cutting guide was then placed. The left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken. After the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size E and distal femur. This was placed slightly in lateral position and secured in position with spring tense and head lift tense. Once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately. The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws. After this was performed, the guide was removed and all bony fragments were then removed. Attention was then directed to the tibia. The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position. Care was ensured if it is was a varus or valgus and the appropriate. The femur gauge was then used to provide us appropriate amount of bony resection. This was then pinned and secured into place. Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made. This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained. Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability. The trial components were then removed. The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment. After it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact. Again the trial components were placed back into position. Patella button was placed and the tracking was evaluated. They tracked centrally with no touch technique. Again, all components were now removed and the knee was then copiously irrigated and suctioned dry. Once adequately suctioned dry, the tibial portion was cemented and packed into place. Also excess cement was removed. The femoral component was then cemented into position. All excess cement was removed. A size 12 poly was then inserted in trial to provide compression at cement adhered. The patella was then cemented and held into place. All components were held under compression until cement had adequately adhered all excess cement was then removed. The knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice. The knee was again copiously irrigated and suctioned dry. One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place. After this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components. The knee was once again copiously irrigated, and the tourniquet was deflated. Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained. A drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 Ethibond and oversewn with a #1 Vicryl. This was flexed and the repair was found held securely. At this point, the knee was again copiously irrigated and suctioned dry. The subcutaneous tissue was closed with #2-0 Vicryl, and the skin was approximated with skin staples. Sterile dressing with Adaptic, 4x4s, ABDs, and Kerlix rolls was then applied. The patient was then transferred back to the gurney in a supine position.,DISPOSITION: , The patient tolerated well with no complications, to PACU in satisfactory condition.
## 77 PREOPERATIVE DIAGNOSIS:, Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:, Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella. All components were cemented with Cobalt G.,ANESTHESIA:, Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Less than 60 minutes.,The patient was taken to the Postanesthesia Care Unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: ,The patient is a 51-year-old female complaining of worsening right knee pain. The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling. The patient requested surgical intervention and need for total knee replacement.,All risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent. All risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent. The patient was given antibiotics preoperatively.,PROCEDURE DETAIL: ,The patient was taken to the operating suite and placed in supine position on the operating table. She was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well. The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh. Right lower extremity was prepped and draped in sterile fashion. All extremities were padded prior to this.,The right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case. A midline incision was made over the right knee and medial parapatellar arthrotomy was performed. Patella was everted. The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed. The posterior cruciate ligament was intact.,There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment. The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,At the extramedullary tibial guide, an extended cut was made adjusting for her alignment. Once this was performed, excess bone was removed. The reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur. Once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion. Excess bone was removed.,Next, the tibia was brought anterior and excised to 71 mm. It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia. Once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,Next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed. The knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability. There was no loosening appreciated. There is no laxity appreciated along the posterior cruciate ligament.,Once this was performed, the trial components were removed. The knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being Cobalt G, it was placed on the tibia. The tibial components were tagged in position and placed on the femur. The femoral components were tagged into position. All excess cement was removed ___ placement of patella. It was tagged in position. A 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed. The cement hardened with the knee in full extension, after which any extra cement was removed.,The wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 Vicryl. Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples. The patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition. The patient tolerated the procedure well.
## 78 PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:, Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1. Removal of antibiotic spacer.,2. Revision total hip arthroplasty.,IMPLANTS,1. Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2. Zimmer femoral component, 13.5 x 220 mm with a size AA femoral body.,3. A 32-mm femoral head with a +0 neck length.,ANESTHESIA: ,Regional.,ESTIMATED BLOOD LOSS: , 500 cc.,COMPLICATIONS:, None.,DRAINS: , Hemovac times one and incisional VAC times one.,INDICATIONS:, The patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma. This subsequently became infected. She has undergone removal of this prosthesis and placement of antibiotic spacer. She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room by anesthesia personnel. She was placed supine on the operating table. A Foley catheter was inserted. A formal time out was obtained in identifying the correct patient, operative site. Preoperative antibiotics were held for intraoperative cultures. The patient was placed into the lateral decubitus position with the right side up. The previous surgical incision was identified. The right lower extremity was prepped and draped in standard fashion. The old surgical incision was reopened along its proximal extent. Immediately encountered was a large amount of fibrous scar tissue. Dissection was carried sharply down through this scar tissue. Soft tissue plains were extremely difficult to visualize due to all the scarring. There was no native tissue to orient oneself with. We carried our dissection down through the scar tissue to what seemed to be a fascial layer. We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter. Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed. This was used as a landmark to orient remainder of the dissection. The antibiotic spacer was exposed and followed distally to expose the proximal femur. Dissection was continued posteriorly and proximally to expose the acetabulum. A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure. Once improved visualization was obtained, the antibiotic spacer was removed from the femur. This allowed further improved visualization of the acetabulum. The acetabulum was filled with soft tissue debris and scar tissue. This was removed with sharp excision with a knife as well as with a rongeur and a Bovie. Once soft tissue was removed, the acetabulum was reamed. Reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell. The 50 mm shell was trialed and had good stability and fit. Attention was then turned to continue preparation of the femur. The canal was then debrided with femoral canal curettes. Some fibrous tissue was removed from the canal. The length of the femoral stem was then checked with this canal curette in place. Following x-rays, we prepared to begin reaming the femur. This femur was reamed over a guide rod using flexible reaming rods. The canal was reamed up to 13.5 mm distally in preparation for 14 mm stem. The stem was selected and initially size A body was placed in trial. The body was too tight proximally to fit. The proximal canal was then reamed for a size AA body. A longer stem with an anterior bow was selected and a size AA trial was assembled. This fit nicely in the canal and had good fit and fill. Intraoperative radiographs were obtained to determine component position. Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur. The remainder of the trial was then assembled and the hip was relocated and trialed. Initially, it was found to be unstable posteriorly. We changed from a 10 degree lip liner to 20 degree lip liner. Again, the hip was trialed and found to be unstable posteriorly. This was due to reversion of the femoral component. As we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion. The stem was extracted and retrialed. Improved stability was obtained and we decided to proceed with the real components. A 20 degree liner was inserted into the acetabular shell. The real femoral components were assembled and inserted into the femoral canal. Again, the hip was trialed. The components were found to be in relative retroversion. The real components were then backed down and the neck was placed in the more anteversion and reinserted. Again, the stem attempted to follow in the relative retroversion. Along with this time, however, it was improved from previous attempts. The femoral head trial was placed back on the components and the hip relocated. It was taken to a range of motion and found to have improved stability compared to previous trialing. Decision was made to accept the component position. The real femoral head was selected and implanted. The hip was then taken again to a range of motion. It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation. The patient reached full extension and had no instability anteriorly.,The wound was then irrigated again with pulsatile lavage. Six liters of pulsatile lavage was used during the procedure.,The wound was then closed in a layered fashion. A Hemovac drain was placed deep to the fascial layer. The subcutaneous tissues were closed with #1 PDS, 2-0 PDS, and staples in the skin. An incisional VAC was then placed over the wound as well. Sponge and needle counts were correct at the close of the case.,DISPOSITION:, The patient will be weightbearing as tolerated with posterior hip precautions.
## 79 PREOPERATIVE DIAGNOSIS:, Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL TOURNIQUET TIME: , Approximately 90 minutes.,SPECIFICATIONS: , The entire procedure is done in the inpatient operating suite in the Room #1 at ABCD General Hospital. The following sizes of NexGen system were utilized: E on right femur, cemented; 5 tibial stem tray with a 10 mm polyethylene insert, and a 32 mm patellar button.,HISTORY AND GROSS FINDINGS: , This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention. She was completely refractory to conservative outpatient therapy. She had undergone two knee arthroscopies in the years preceding this. They were performed by myself. She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live. Medial compartment had minor changes present. There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides. There was no significant flexion contracture preoperatively.,OPERATIVE PROCEDURE: ,The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department. Thigh tourniquet was placed upon the patient's right leg. She was prepped and draped in the usual sterile manner. The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time. A straight incision was carried down through the skin and subcutaneous tissue. Hemostasis was controlled with electrocoagulation. Medial parapatellar arthrotomy was created and the knee cap was everted. The ligaments were balanced. A portion of the fat pad was removed and the ACL was completely removed. Drill hole was made in the distal femur. The size to an E, right. Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side. This was checked with the epicondylar abscess and with three degrees of external rotation, drill holes were made. Intramedullary guide was then placed, pegged, and anterior cut carried out. There was excellent resection. It was flat. Distal cutting guide was then placed in five degrees of valgus. Appropriate cuts were carried out. The standard cut was utilized.,The finishing guide for E was held with pins as well as screws. Cutting was carried out posterior to anterior, then posterior chamfer and anterior chamfer, femoral sulcus cut was carried out and drill holes for pegs were made. The cutting guide was then removed. The bone was removed. Excess bone was taken out posteriorly. The posterior capsule was loosened up. There were two different fabellas in the posterolateral compartment and they were loosened. Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner. An extramedullary tibial cutting guide was then placed, pinned, and held. A cut was carried out parallel to the foot. Hard copy ________ was obtained, deemed to be satisfactory after evening up the edges. Trial range of motion was satisfactory. It was necessary to perform a lateral retinacular release to the patella. The patella was isolated. Approximately 10 mm to 11 mm were reamed off. The size to 32 mm button and drill hole guide was placed, impacted, and drilled. Trial range of motion was satisfactory. The tibial guide was then pinned. Drill hole was placed, broached, and utilized. Copious irrigation was carried out. Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella. The implants were sequentially placed in tibia to femur to patella. Once excess methylmethacrylate was removed and cured, 10 mm Poly was placed. There was excellent ligament balancing. A separate portal was utilized for subcutaneous drain. Tourniquet was deflated and hemostasis was controlled with electrocoagulation. Interrupted #1 Ethibond suture was utilized for parapatellar closure, running #1 Vicryl suture was utilized for overstitch.,Trial range of motion was satisfactory. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin. Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing. Digits were pink and warm with brawny pulses distally at the end of the case. The patient was then transferred to PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair.
## 80 PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED: ,Total hip arthroplasty on the left.,ANESTHESIA: ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS: ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis. This was revealed once we removed the trochanteric bursa.,HISTORY: ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis. She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure. All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure. The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03. The general anesthetic was first performed by the Department of Anesthesia. The patient was then positioned with the left hip exposed on the beanbag in the lateral position. Kidney rests were also used because of the patient's size. An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse. All her bony prominences were well padded. At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure. At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat. The tensor fascia lata was then identified. A self-retainer was then inserted to expose the operative field. Bovie cautery was used for hemostasis. At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter. At this time, a blunt dissection was taken proximally. The tensor fascia lata was occluded with a hip retractor. At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius. At this time, a periosteal elevator was used to expose anterior hip capsule. A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle. Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck. At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum. At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum. At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum. At this time, a femoral stem guide was then used to measure proximal femoral neck cut. We made a cut approximately a fingerbreadth above the lesser trochanter. At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed. At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum. A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum. With better exposure of the acetabulum, we started reaming the acetabulum. We started with a size #44 and progressively reamed to a size #50. At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum. We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum. A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in. Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum. At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup. At this time, a plastic liner was then inserted for protection. The leg was then placed back in the bag. A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur. A rongeur was used to lateralize over the greater trochanter. A Box osteotome was used to remove the cancellous portion of the femoral neck. A Charnley awl was then used to cannulate through the proximal femoral canal. A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem. At this time, we began broaching. We started with a size #10 and progressively worked up to a size #12 mm broach. Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar. A calcar reamer was then placed and the calcar was reamed smoothly. A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed. Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation. At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum. This was impacted and placed and checked to assure that it was well seated with no loosening. Once this was performed, we then exposed the proximal femur one more time. We copiously irrigated within the canal and then suctioned it dry. At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place. Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none. The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion. We were satisfied with components as well as the alignment of the components. Copious irrigation was then used to irrigate the wound. #1 Ethibond was then used to approximate the anterior hip capsule. #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter. Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure. A tight closure was performed. Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin. Staples were then used for skin closure. The patient's hip was then cleansed. Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed. A drain was placed prior to wound closure for postoperative drainage. After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition. Prognosis is good.
## 81 PROCEDURE:, Total hip replacement.,PROCEDURE DESCRIPTION:, The patient was bought to the operating room and placed in the supine position. After induction of anesthesia, the patient was turned on the side and secured in the hip table. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. The gluteus maximus was incised and split proximally. The piriformis and external rotators were identified. These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule. The hip was dislocated. A femoral neck cut was made using the guidance of preoperative templating. The femoral head was removed. Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken. The femur was retracted anteriorly and a complete labrectomy was performed. Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas. The trial shell was placed and found to have an excellent fit. The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction. Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw. Excellent purchase was obtained. The trial liner was placed.,The femur was then flexed and internally rotated. The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion. An intramedullary hole was drilled into the femur to define the canal. Reaming was performed until the appropriate size was reached. The broaches were then used to prepare the femur with the appropriate amount of version. Once the appropriate size broach was reached, it was used as a trial with head and neck placement. Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation. The hip was found to have excellent stability with the final chosen head-neck combination. Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position. The real head was impacted atop the stem. If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version. Excess cement was removed from the edges of the component. Range of motion and stability were once again checked and found to be excellent. Adequate hemostasis was obtained. Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy. The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl. The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures. The skin was closed with nylon. Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap. The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.
## 82 PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1. Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2. Trabecular metal modular acetabular system 48 mm in diameter.,3. Femoral head 32 mm diameter +0 mm neck length.,4. Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:, The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up. After review of allergies, antibiotics were administered and time out was performed. The right lower extremity was prepped and draped in a sterile fashion. A 15 cm to 25 cm in length, an incision was made over the greater trochanter. This was angled posteriorly. Access to the tensor fascia lata was performed. This was incised with the use of scissors. Gluteus maximus was separated. The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie. Hemostasis was achieved. The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb. It was detached from the piriformis fossa and tagged with 2-0 Vicryl. Access to the capsule was performed. The capsule was excised from the posterior and superior aspects. It was released also in the front with the use of a Mayo scissors. The hip was then dislocated. With the use of an oscillating saw, the femoral neck cut was performed. The acetabulum was then visualized and debrided from soft tissues and osteophytes. Reaming was initiated and completed for a 48 mm diameter cap without complications. The trial component was put in place and was found to be stable in an anatomic position. The actual component was then impacted in the acetabulum. A 10-degree lip polyethylene was also placed in the acetabular cap. Our attention was then focused to the femur. With the use of a cookie cutter, the femoral canal was accessed. The broaching process was initiated for No.4 trial component. Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation. In addition, in full extension and external rotation, there was no dislocation. The actual component was inserted in place and hemostasis was achieved again. The wound was irrigated with normal saline. The wound was then closed in layers. Before performing that the medium-sized Hemovac drain was placed in the wound. The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl. Staples were used for the skin. The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition. She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions. We will start the DVT prophylaxis after the removal of the epidural catheter.
## 83 PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Abnormal uterine bleeding.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Abnormal uterine bleeding.,PROCEDURE PERFORMED: , Total abdominal hysterectomy with a uterosacral vault suspension.,ANESTHESIA: , General with endotracheal tube as well as spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 150 cc.,URINE OUTPUT: ,250 cc of clear urine at the end of the procedure.,FLUIDS:, 2000 cc of crystalloids.,COMPLICATIONS: , None.,TUBES: , None.,DRAINS: ,Foley to gravity.,PATHOLOGY: , Uterus, cervix, and multiple fibroids were sent to pathology for review.,FINDINGS: ,On exam, under anesthesia, normal appearing vulva and vagina, a massively enlarged uterus approximately 20 weeks' in size with irregular contours suggestive of fibroids.,Operative findings demonstrated a large fibroid uterus with multiple subserosal and intramural fibroids as well as there were some filmy adnexal adhesions bilaterally. The appendix was normal appearing. The bowel and omentum were normal appearing. There was no evidence of endometriosis. Peritoneal surfaces and vesicouterine peritoneum as well as appendix and cul-de-sac were all free of any evidence of endometriosis.,PROCEDURE:, After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the Operating Room where first a spinal anesthesia with Astramorph was obtained without any difficulty. She then underwent a general anesthesia with endotracheal tube also without any difficulty. She was then examined under anesthesia with noted findings as above. The patient was then placed in dorsal supine position and prepped and draped in the usual sterile fashion.. A vertical skin incision was made 1 cm below the umbilicus extending down to 2 cm above the pubic symphysis. This was made with a first knife and then carried down to the underlying layer of the fascia with the second knife. Fascia was excised in the midline and extended superiorly and inferiorly with the Mayo scissors. The rectus muscle was then separated in the midline. The peritoneum identified and entered bluntly. The peritoneal incision was then extended superiorly and inferiorly with external visualization of the bladder. The uterus was markedly evident upon entering the peritoneal cavity. The uterus was then exteriorized and noted to have the findings as above. At this point, approximately 10 cc of vasopressin 20 units and 30 cc was injected into the uterine fundus and multiple fibroids were removed by using the incision with the Bovie and then using a blunt and the sharp dissection and grasping with Lahey clamps. Once the debulking of the uterus was felt appropriate to proceed with the hysterectomy, the uterus was then reapproximated with a few #0 Vicryl sutures in a figure-of-eight fashion. The round ligaments were identified bilaterally and clamped with the hemostats and transacted with the Metzenbaum scissors. The round ligaments were then bilaterally tied with the #0 tie and noted to be hemostatic. The uterovarian vessels bilaterally were then isolated through a vascular window created from taking down the round ligaments. The uterovarian vessels bilaterally were #0 tied and then doubly clamped with straight Ochsner clamps and transacted and suture tied with a Heaney hand stitch fashion, and both uterine and ovarian vessels were noted to be hemostatic. At this time, the attention was then turned to the vesicouterine peritoneum, which was tented up with Allis clamps and the bladder flap was then created sharply with Russian pickups and the Metzenbaum scissors. Then the bladder was bluntly dissected off the underlying cervix with a moist Ray-Tec sponge down to the level of the cervix.,At this point, the uterus was pulled on traction and the uterosacral ligaments were easily visualized. Using #2-0 PDS suture, the suture was placed through both uterosacral ligaments distally with a backhand stitch fashion throwing the sutures from lateral to medial. These sutures were then tagged and saved for later. The uterine vessels were then identified bilaterally and skeletonized, then clamped with straight Ochsner clamps balancing off the cervix, and the uterine vessels were then transacted and suture ligated with #0 Vicryl and noted to be hemostatic. In a similar fashion, the broad ligament down to the level of the cardinal ligaments was clamped with curved Ochsner and transacted and suture ligated and noted to be hemostatic. At this point, the Lahey clamp was placed on the cervix and the cervix was tented up. The pubocervical vesical fascia was transacted with long knife. Then while protecting posteriorly, using the double-pointed scissors, the vagina was entered with double-pointed scissors at the level of the cervix and was grasped with a straight Ochsner clamp. The uterus and cervix were then amputated using the Jorgenson scissors and the cuff was outlined with Ochsner clamps. The cuff was then copiously painted with Betadine soaked sponge. The Betadine-soaked sponge was placed in the patient's vagina. Then the cuff was then closed with a #0 Vicryl in a running locked fashion to make sure to bring the ipsilateral cardinal ligaments into the vaginal cuff. This was accomplished with one #0 Vicryl running stitch and then an Allis clamp was placed in the midsection portion of the cuff and tented up and a #0 Vicryl figure-of-eight was placed in the midsection portion of the cuff. At this time, the uterosacral ligaments previously tagged needle was brought through the cardinal ligament and the uterosacral ligament on the ipsilateral side. The needle was cut off and these were then tagged with the hemostats. The cuff was then closed by taking the running suture and bringing back through the posterior peritoneum, grabbing part of the uterosacral and midsection portion of the posterior peritoneum of the uterosacral and then tying the cuff down to bunch and cuff together. The suture in the midportion of the cuff was then used to tie down the round ligaments bilaterally to the cuff. The abdomen was copiously irrigated with warm normal saline. All areas were noted to be hemostatic. Then the previously tagged uterosacral sutures were then tied bringing the vaginal cuff angles down to the uterosacral ligaments. The abdomen was then once again copiously irrigated with warm normal saline. All areas were noted to be hemostatic. The sigmoid colon was replaced back into the hollow of the sacrum. Then the omentum was pulled over the bowel. After the myomectomy was performed, the GYN Balfour was placed into the patient's abdomen and the bowel was packed away with moist laparotomy sponges. The GYN Balfour was then removed. Packing sponges were removed and the fascia was then closed in an interrupted figure-of-eight fashion with #0 Vicryl.,Skin was closed with staples. The patient tolerated the procedure well. The sponge, lap, and needle counts were correct x2. The sponge from the patient's vagina was removed and the vagina was noted to be hemostatic. The patient would be followed throughout her hospital stay.
## 84 PREOPERATIVE DIAGNOSIS:, Aortic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Aortic stenosis.,PROCEDURES PERFORMED,1. Insertion of a **-mm Toronto stentless porcine valve.,2. Cardiopulmonary bypass.,3. Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 300 cc.,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid.,URINE OUTPUT: , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:, After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next the neck, chest and legs were prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make a midline median sternotomy incision. Dissection was carried down to the left of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw. The chest retractor was positioned. Next, full-dose heparin was given. The pericardium was opened. Pericardial stay sutures were positioned. After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass. A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta. Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine. Next a 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine. A 4-0 U-stitch was placed in the right atrium. A retrograde cardioplegia catheter was positioned at this site. Next, scissors were used to dissect out the right upper pulmonary vein. A 4-0 Prolene pursestring was placed in the right upper pulmonary vein. Next, a right-angle sump was placed at this position. We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit. Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery. The aorta was completely encircled. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. We then prepared to cross-clamp the aorta. We went down on our flows and cross-clamped the aorta. We backed up our flows. We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart. The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit. Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures. In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view. Next, scissors were used to excise the diseased aortic valve leaflets. Care was taken to remove all the calcium from the aortic annulus. We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve. We prepared the valve. Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus. We started with our individual commissural stitches. They were connected to our valve sewing ring. Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position. After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve. The valve was lowered into place and all of the sutures were tied. Next, we gave another round of cold blood antegrade and retrograde cardioplegia. Next, we sewed our distal suture line. We began with the left coronary cusp of the valve. We ran a 5-0 RB needle up both sides of the valve. Care was taken to avoid the left coronary ostia. This procedure was repeated on the right cusp of the stentless porcine valve. Again, care was taken to avoid any injury to the coronary ostia. Lastly, we sewed our non-coronary cusp. This was done without difficulty. At this point we inspected our aortic valve. There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open. We gave another round of cold blood antegrade and retrograde cardioplegia. The antegrade portion was given in a direct ostial fashion once again. We now turned our attention to closing the aorta. A 4-0 Prolene double row of suture was used to close the aorta in a running fashion. Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia. At this point, we removed our aortic cross-clamp. The heart gradually regained its electromechanical activity. We placed 2 atrial and 2 ventricular pacing wires. We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle. We removed our retrograde cardioplegia catheter. We oversewed that site with a 5-0 Prolene. By now, the heart was de-aired and resumed normal electromechanical activity. We began to wean the patient from cardiopulmonary bypass. We then removed our venous cannula and suture ligated that site with a #2 silk. We then gave full-dose protamine. After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula. We buttressed that site with a 4-0 Prolene on an SH needle. We placed a mediastinal chest tube and brought it out through the skin. We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions. They were brought out through the skin. The sternum was closed with #7 wires in an interrupted figure-of-eight fashion. The fascia was closed with #1 Vicryl. We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.
## 85 PREOPERATIVE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Anemia.,3. Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Anemia.,3. Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: , 150 mL.,COMPLICATIONS: , None.,FINDING: ,Large fibroid uterus.,PROCEDURE IN DETAIL: ,The patient was prepped and draped in the usual sterile fashion for an abdominal procedure. A scalpel was used to make a Pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia. The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors. The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles. The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel. The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel. The O'Connor-O'Sullivan instrument was then placed without difficulty. The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty. The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus. This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty. Hemostasis was noted at this point of the procedure. The bladder flap was then developed free from the uterus without difficulty. Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side. This was done without difficulty. The uterine fundus was then separated from the uterine cervix without difficulty. This specimen was sent to pathology for identification. The cervix was then developed with careful dissection. Jorgenson scissors were then used to remove the cervix from the vaginal cuff. This was sent to pathology for identification. Hemostasis was noted at this point of the procedure. A #1 chromic suture ligature was then used in running fashion at the angles and along the cuff. Hemostasis was again noted. Figure-of-eight sutures were then used in an interrupted fashion to close the cuff. Hemostasis was again noted. The entire pelvis was washed. Hemostasis was noted. The peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion. The rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion. The fascia was closed using 0 Vicryl in interlocking running fashion. Foundation sutures were then placed in an interrupted fashion for further closing the fascia. The skin was closed with staple gun. Sponge and needle counts were noted to be correct x2 at the end of the procedure. Instrument count was noted to be correct x2 at the end of the procedure. Hemostasis was noted at each level of closure. The patient tolerated the procedure well and went to recovery room in good condition.
## 86 <NA>
## 87 PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Pelvic pain.,3. Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS: ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:, This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus. On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm. She had received two dosage of Lupron to help shrink the fibroid. Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated. On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm. The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament. There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:, After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic. The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion. A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife. The fascia was incised in midline and the incision extended laterally using Mayo scissors. The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors. Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles. The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors. This incision was extended superiorly and inferiorly with good visualization of the bladder. The uterus was then brought up out of the incision. The bowel adhesions were carefully taken down using Metzenbaum scissors. Good hemostasis was noted at this point. The self-retaining retractor was then placed. The bladder blade was placed. The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension. The uterus was then grasped with a Lahey clamp and brought up out of the incision. The left round ligament was identified and grasped with Allis clamp and tented up. A hemostat was passed in the avascular area beneath the round ligament. A suture #0 Vicryl was used to suture ligate the round ligament. Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament. An avascular area of the broad ligament was then identified and entered bluntly. The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament. Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture. The ligament was then transected and suture ligated with #0 Vicryl. Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp. An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected. An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture. This was then transected and suture ligated again with #0 Vicryl. The left uterine peritoneum was then identified and grasped with Allis clamps. The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors. This incision was extended across the anterior portion of the uterus and the bladder flap was taken down. It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec. The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix. The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's. Each were then transected and suture ligated with #0 Vicryl. A curved Ochsner was then placed on either side of the cervix. The tissue was transected using a long knife and suture ligated with #0 Vicryl. Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie. The cervix was then grasped with a Lahey clamp. The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix. A double-pointed scissors were used to enter the vaginal vault below the level of the cervix. A straight Ochsner was placed on the vaginal vault. The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue. The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated. There was a small area of bleeding noted on the underside of the bladder. The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point. The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down. A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament. The round ligament was too short. It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff. The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion. The bladder flap was reapproximated to the vaginal cuff using one interrupted suture. The pelvis was again irrigated at this point with excellent hemostasis noted. Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder. There was no spillage of blue fluid into the abdomen. The fluid again was allowed to drain. All sponges were then removed and the bowel was allowed to return to its anatomical position. The peritoneum was then reapproximated with #0 Vicryl in a running fashion. The fascia was reapproximated also with #0 Vicryl in a running fashion. The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault. There was no appreciable bleeding. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room in satisfactory condition. She will be followed immediately postoperatively within the hospital.
## 88 POSTOPERATIVE DIAGNOSIS:, Chronic adenotonsillitis.,PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: ,General endotracheal tube.,ESTIMATED BLOOD LOSS:, Minimum, less than 5 cc.,SPECIMENS:, Right and left tonsils 2+, adenoid pad 1+. There was no adenoid specimen.,COMPLICATIONS: , None.,HISTORY: , The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. The patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years.,PROCEDURE: , Informed consent was properly obtained from the patient's parents and the patient was taken to the operating room #3 and was placed in a supine position. He was placed under general endotracheal tube anesthesia by the Department of Anesthesia. The bed was then rolled away from Department of Anesthesia. A shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap. The McIvor mouth gag was carefully positioned into the patient's mouth with attention to avoid the teeth.,The retractor was then opened and the oropharynx was visualized. The adenoid pad was then visualized with a laryngeal mirror. The adenoids appeared to be 1+ and non-obstructing. There was no evidence of submucosal cleft palate palpable. There was no evidence of bifid uvula. A curved Allis clamp was then used to grasp the superior pole of the right tonsil. The tonsil was then retracted inferiorly and medially. Bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection. The tonsil was then dissected out within this plane using a Bovie. Tonsillar sponge was re-applied to the tonsillar fossa. Suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa. Attention was then directed to the left tonsil. The curved Allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially. Bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection. The tonsil was then dissected out within this plane using the Bovie. Next, complete hemostasis was achieved within the tonsillar fossae using suction cautery. After adequate hemostasis was obtained, attention was directed towards the adenoid pad. The adenoid pad was again visualized and appeared 1+ and was non-obstructing. Decision was made to use suction cautery to cauterize the adenoids. Using a laryngeal mirror under direct visualization, the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates. After cauterization was complete, the nasopharynx was again visualized and tonsillar sponge was applied. Adequate hemostasis was achieved. The tonsillar fossae were again visualized and no evidence of bleeding was evident. The throat pack was removed from the oropharynx and the oropharynx was suctioned. There was no evidence of any further bleeding. A flexible suction catheter was then used to suction out the nasopharynx to the oropharynx. The suction catheter was also used to suction up the stomach. Final look revealed no evidence of further bleeding and 10 mg of Decadron was given intraoperatively.,DISPOSITION: ,The patient tolerated the procedure well and the patient was transported to the recovery room in stable condition.
## 89 PREOPERATIVE DIAGNOSES,1. Recurrent tonsillitis.,2. Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3. Residual adenoid hypertrophy and recurrent epistaxis.,POSTOPERATIVE DIAGNOSES,1. Recurrent tonsillitis.,2. Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3. Residual adenoid hypertrophy and recurrent epistaxis.,FINAL DIAGNOSES,1. Recurrent tonsillitis.,2. Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3. Residual adenoid hypertrophy and recurrent epistaxis.,OPERATION PERFORMED,1. Tonsillectomy and adenoidectomy.,2. Left superficial nasal cauterization.,DESCRIPTION OF OPERATION:, The patient was brought to the operating room. Endotracheal intubation carried out by Dr. X. The McIvor mouth gag was inserted and gently suspended. Afrin was instilled in both sides of the nose and allowed to take effect for a period of time. The hypertrophic tonsils were then removed by the suction and snare. Deeply cryptic changes as expected were evident. Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation. An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive. They were shaved back, flushed with prevertebral fascia with curette. Hemostasis established with packing followed by electrocautery. In light of his history of recurring nosebleeds, both sides of the nose were carefully inspected. A nasal endoscope was used to identify the plexus of bleeding, which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device. The bleeding was admittedly a bit of a annoyance. An additional control was established by infiltrating slowly with a 1% Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself. No additional bleeding was then evident. The oropharynx was reinspected, clots removed, the patient was extubated, taken to the recovery room in stable condition. Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops. Office recheck anticipated if stable and doing well in three to four weeks.
## 90 PREOPERATIVE DIAGNOSIS:, Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS: ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance. She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY: ,The patient was brought to the operative suite and placed supine on the operating room table. General anesthetic was administered. Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy. He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx. Under an operating headlight, the oropharynx was clearly visualized. The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa. This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris. Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts. With the tonsils removed, it was possible to visualize the adenoid pads. The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique. The adenoid pad was greater than 2+/4 and hypertrophic. It was removed with successive passes of electrocautery suction. The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle. The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period. The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic. She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal. There were no complications. Specimens produced were right and left tonsils. The adenoid pad was ablated with electrocautery.
## 91 PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:, General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia. The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied. Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,The nasopharynx was inspected with a laryngeal mirror. The adenoid tissue was fulgurated with the suction Bovie set at 35. The catheters and the dental gauze roll were then removed. The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine. Using the radiofrequency wand, the tonsils were ablated bilaterally. If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9. The tonsillectomy was completed.,The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
## 92 PREOPERATIVE DIAGNOSIS:, Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,POSTOPERATIVE DIAGNOSIS:, Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,OPERATION:, Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty.,ANESTHESIA:, General anesthetics.,HISTORY: , This is a 51-year-old gentleman here with his wife. She confirms the history of loud snoring at night with witnessed apnea. The result of the sleep study was reviewed. This showed moderate sleep apnea with significant desaturation. The patient was unable to tolerate treatment with CPAP. At the office, we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate. A tortuous appearance of the septum also was observed. This morning, I talked to the patient and his wife about the findings. I reviewed the CT images. He has no history of sinus infections and does not recall a history of nasal trauma. We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway. Depending on the findings of surgery, I explained that I might remove that bone spur that we are seeing within the nasal passage. I will get the best look at it when he is asleep. We discussed recovery as well. He visited with Dr. XYZ about the anesthetic produce.,PROCEDURE:,: General tracheal anesthetic was administered by Dr. XYZ and Mr. Radke. Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose. A Crowe-Davis mouth gag was placed. The tonsils were very large and touched the uvula. The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars. Also, there was a cryptic appearance of the tonsils but there was no acute redness or exudate. Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present. A very crowded pharynx was appreciated. The tonsils were first removed using electrodissection technique. Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut. The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine. There already was more room in the pharynx, but the posterior pharyngeal wall was still obscured by the soft palate and uvula. The uvula was grasped with the Alice clamp. I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate. We switched over from the Bayonet cautery to the blunt needle tip electrocautery. The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate, and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar. This incision was then deepened with the electrocautery on a cutting current. The uvular artery just to the right of the midline was controlled with the suction electrocautery. The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty. A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology. The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine. The soft palate was also injected with 0.25% Marcaine with 1:200,000 epinephrine. The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures. The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3-0 chromic catgut sutures. A much improved appearance of the oropharynx with a greatly improved airway was appreciated. A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed. I removed the cottonoids from both nostrils. Speculum exam showed the inferior turbinates were large, the septum was tortuous and it angulated to the right and then sharply bent back to the left. The septum was injected with 0.25% Marcaine with 1:200,000 epinephrine using a separate syringe and needle. A #15 blade was used to make a left cheilion incision.,Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator. When we reached the deflected portion of the vomer, this was separated from the septal cartilage with a Freer elevator. The right-sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome, the deflected portion of the septal bone from the vomer was resected. This tissue also was sent as a separate specimen to pathology. The intraseptal space was irrigated with saline and suctioned. The nasal septal mucosal flaps were then sutured together with a quilting suture of 4-0 plain catgut. I observed no evidence of purulent secretion or polyp formation within the nostrils. The inferior turbinates were then both outfractured using a knife handle, and now there was a much more patent nasal airway on both sides. There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose. No packing was used in the nostrils. Polysporin ointment was introduced into both nostrils. The mouth gag was reintroduced and the pack removed from the nasopharynx. The nose and throat were irrigated with saline and suctioned. An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed. Sponge and needle count were reported correct. The mouth gag having been withdrawn, the patient was then awakened and returned to recovery room in a satisfactory condition. He tolerated the operation excellently. Estimated blood loss was about 15-20 cc. In the recovery room, I observed that he was moving air well and I spoke with his wife about the findings of surgery.
## 93 PREOPERATIVE DIAGNOSIS:, Chronic tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis.,PROCEDURE: ,Tonsillectomy.,DESCRIPTION OF PROCEDURE: , Under general orotracheal anesthesia, a Crowe-Davis mouth gag was inserted and suspended. Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0.25% plain. A catheter was inserted in the nose and brought out from mouth. The throat was irrigated with saline. There was no further bleeding. The patient was awakened and extubated and moved to the recovery room in satisfactory condition.
## 94 PREOPERATIVE DIAGNOSIS: , Tonsillitis.,POSTOPERATIVE DIAGNOSIS: ,Tonsillitis.,PROCEDURE PERFORMED: ,Tonsillectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room and prepped and draped in the usual fashion. After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction. The nasopharynx was inspected with the laryngeal mirror.,Attention was then directed to the right tonsil. The anterior tonsillar pillar was infiltrated with 1.5 cc of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar. The right tonsil was grasped with the tenaculum and retracted out of its fossa. The anterior tonsillar pillar was incised with the #12 knife blade. The plica semilunaris was incised with the Metzenbaum scissors. Using the Metzenbaum scissors and the Fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied. The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described. By a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,Attention was re-directed to the right tonsil. The pack was removed and bleeding was controlled with the suction Bovie unit. Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs. The catheters were then removed. The nasal passages and oropharynx were suctioned free of debris. The procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
## 95 PREOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:, Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:, General.,HISTORY: , The patient is 5-1/2 years old. She is here this morning with her Mom. She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well. At the office we saw the tonsils were very big. There was a rock in the right ear and it was very deep in the canal, near the drum. We will remove the foreign body under the same anesthetic.,PROCEDURE:,: Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B. I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum. On the right side, I took out some impacted wax and removed the rock with a large suction. It was actually resting on the surface of the drum but had not scarred or damaged the drum. The drum was intact with no evidence of middle ear fluid. The microscope was set aside. Afrin drops were placed in both nostrils. The neck was gently extended and the Crowe-Davis mouth gag inserted. The tonsils and adenoids were very large. The uvula was intact. Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx. Tonsillectomy accomplished by sharp and blunt dissection. Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine. Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds. Sponge is removed from the nasopharynx. The suction electrocautery was used for pinpoint hemostasis on the adenoid bed. We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices. The nose and throat were then irrigated with saline and suctioned. Excellent hemostasis was observed. An orogastric tube was placed. The stomach found to be empty. The tube was removed, as was the mouth gag. Sponge and needle count were reported correct. The child was then awakened and prepared for her to return to the recovery room. She tolerated the operation excellently.
## 96 PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:, Under general anesthesia with an endotracheal tube, the patient was placed in supine position. A mouth gag was inserted and suspended from Mayo stand. Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate. The adenoid area was inspected. The adenoids were small. The left tonsil was grasped with a tonsil tenaculum. The tonsil was removed with the Gold laser. The apposite tonsil was removed in a similar manner. Hemostasis was secured with electrocautery. Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline. The patient tolerated the procedure well and left the operating room in good condition.
## 97 PREOPERATIVE DIAGNOSIS: , Thyroid goiter.,POSTOPERATIVE DIAGNOSIS: ,Thyroid goiter.,PROCEDURE PERFORMED: , Total thyroidectomy.,ANESTHESIA:,1. General endotracheal anesthesia.,2. 9 cc of 1% lidocaine with 1:100,000 epinephrine.,COMPLICATIONS:, None.,PATHOLOGY: , Thyroid.,INDICATIONS: ,The patient is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter. A thyroidectomy was indicated at this time secondary to the patient's chronic condition. Indications, alternatives, risks, consequences, benefits, and details of the procedure including specifically the risk of recurrent laryngeal nerve paresis or paralysis or vocal cord dysfunction and possible trach were discussed with the patient in detail. She agreed to proceed. A full informed consent was obtained.,PROCEDURE: , The patient presented to ABCD General Hospital on 09/04/2003 with the history was reviewed and physical examinations was evaluated. The patient was brought by the Department of Anesthesiology, brought back to surgical suite and given IV access and general endotracheal anesthesia. A 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch. Time is allowed for full hemostasis to be achieved. The patient was then prepped and draped in the normal sterile fashion. A #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area. Unipolar electrocautery was utilized for hemostasis. Finger dissection was carried out in the superior and inferior planes. Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions using hemostat, Metzenbaum, and blunt dissection. The strap muscles were identified. The midline raphe was not easily identifiable at this time. An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid. Sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side. It was noted at this time that the thyroid lobule on the right side is a bi-lobule. Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, force in the lateral direction. This was carried down to the inferior and superior areas. The superior pole of the right lobule was then identified. A hemostat was placed in the cricothyroid groove and a Kitner was placed in this area. A second Kitner was placed on lateral aspect of the superior pole and the superior pole of the right thyroid was retracted inferiorly. Careful dissection was then carried out in a very meticulous fashion in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature. This was carried out until the superior pole was identified. Careful attention was made to avoid nerve injury in this area. Dissection was then carried down again bluntly separating the inferior and superior lobes. The bilobed right thyroid was then retracted medially. The recurrent laryngeal nerve was then identified and tracked to its insertion. The overlying vessels of the middle thyroid vein as well as the associated structures were then identified and great attention was made to perform a right careful meticulous dissection to remove the fascial attachments superficial to the recurrent laryngeal nerve off the thyroid. When it was completed, this lobule was then removed from Berry's ligament. There was noted to be no isthmus at this time and the entire right lobule was then sent to the Pathology for further evaluation. Attention was then diverted to the patient's left side. In a similar fashion, the sternohyoid and sternothyroid muscles were already separated. Army-Navy as well as femoral retractors were utilized to lateralize the appropriate musculature. The middle thyroid vein was identified. Blunt dissection was carried out laterally to superiorly once again. A hemostat was utilized to make an opening in the cricothyroid groove and a Kitner was then placed in this area. Another Kitner was placed on the lateral aspect of the superior lobe of the left thyroid and retracted inferiorly. Once again, a careful meticulous dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis. Once again, a careful attention was made not to injure the nerve in this area. The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects. The inferior aspect was then identified. The inferior thyroid artery and vein were then identified and ligated. The left thyroid was then medialized and the recurrent laryngeal nerve has been identified. A careful dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible. The thyroid was then removed from the Berry's ligament and it was then sent to Pathology for further evaluation. Evaluation of the visceral space did not reveal any bleeding at this time. This was irrigated and pinpoint areas were bipolored as necessary. Surgicel was then placed bilaterally. The strap muscles as well as the appropriate fascial attachments were then approximated with a #3-0 Vicryl suture in the midline. The platysma was identified and approximated with a #4-0 Vicryl suture and the subdermal plane was approximated with a #4-0 Vicryl suture. A running suture consisting of #5-0 Prolene suture was then placed and fast absorbing #6-0 was then placed in a running fashion. Steri-Strips, Tincoban, bacitracin and a pressure gauze was then placed. The patient was then admitted for further evaluation and supportive care. The patient tolerated the procedure well. The patient was transferred to Postanesthesia Care Unit in stable condition.
## 98 OPERATIVE PROCEDURE,1. Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:, The patient was brought to the operating room, placed in supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The chest, abdomen and legs were prepped and draped in a sterile fashion. The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution. The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped. A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The sternum was closed. A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma. The deep fascia was divided. The facial vein was divided between clamps and tied with 2-0 silk. The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk. Shunts were prepared. A patch was prepared. Heparin 50 mg was given IV. Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery. Distal internal was held with a forceps. Internal carotid artery was opened with 11-blade. Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond. The shunt was placed and proximal and distal snares were tightened. Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external. All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line. Suture line was completed and the neck was packed.,The pericardium was opened. A pericardial cradle was created. The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula. A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet. An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted. The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg. This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus. The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture. The vein was cut to length. Antegrade and retrograde cold blood potassium cardioplegia was given. The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein. The vein was cut to length. The mammary was clipped distally, divided and spatulated for anastomosis. Antegrade and retrograde cold blood potassium cardioplegia was given. The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture. Warm blood potassium cardioplegia was given, and the cross-clamp was removed. A partial-occlusion clamp was placed. Two aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. The partial- occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. Ventilation was commenced. The patient was fully warmed. The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.
## 99 PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED: ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region. This was completely excised.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:, None.,DRAINS:, None.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine in position under general anesthesia. First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated. The lesion in the tongue could be seen. Then, it was injected with 1% lidocaine and 1:100,00 epinephrine. After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total. Suction cautery was used for hemostasis. Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.
## 100 PREOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,PROCEDURE:,1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).,2. L4 to S1 fixation (Danek M8 system).,3. Right posterolateral L4 to S1 fusion.,4. Placement of intervertebral prosthetic device (Danek Capstone spacers L4-L5 and L5-S1).,5. Vertebral autograft plus bone morphogenetic protein (BMP).,COMPLICATIONS:, None.,ANESTHESIA:, General endotracheal.,SPECIMENS:, Portions of excised L4-L5 and L5-S1 disks.,ESTIMATED BLOOD LOSS:, 300 mL.,FLUIDS GIVEN:, IV crystalloid.,OPERATIVE INDICATIONS:, The patient is a 37-year-old male presenting with a history of chronic, persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management. Preoperative imaging studies revealed the above-noted abnormalities. After a detailed review of management considerations with the patient and his wife, he was elected to proceed as noted above.,Operative indications, methods, potential benefits, risks and alternatives were reviewed. The patient and his wife expressed understanding and consented to proceed as above.,OPERATIVE FINDINGS:, L4-L5 and L5-S1 disk protrusion with configuration as anticipated from preoperative imaging studies. Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site. In addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. Spacer snugness and positioning appeared satisfactory. Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported.,DESCRIPTION OF THE OPERATION:, After obtaining proper patient identification and appropriate preoperative informed consent, the patient was taken to the operating room on a hospital stretcher in the supine position. After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team, the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed. The patient's posterior lumbosacral region was thoroughly cleansed and shaved. The patient was then scrubbed, prepped and draped in the usual manner. After local infiltration with 1% lidocaine with 1: 200,000 epinephrine solution, a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum. Dissection was continued in the midline to the level of the posterior fascia. Self-retaining retractors were placed and subsequently readjusted as needed. The fascia was opened in the midline, and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3-L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally. _____ by completing the exposure, pedicle screw fixation was carried out in the following manner. Screws were placed in systematic caudal in a cranial fashion. The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed. Cortical openings were created at these sites using a small burr. The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder. They were then probed and subsequently tapped employing fluoroscopic guidance as needed. Each site was "under tapped" and reprobed with satisfactory findings noted as above. Screws in the following dimensions were placed. 6.5-mm diameter screws were placed at all sites. At S1, 40-mm length screws were placed bilaterally. At L5, 40-mm length screws were placed bilaterally, and at L4, 40-mm length screws were placed bilaterally with findings as noted above. The rod was then contoured to span from the L4 to the S1 screws on the right. The distraction was placed across the L4-L5 interspace, and the connections were temporarily secured. Using a matchstick burr, a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level. This was longitudinally oriented. A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle. This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs, and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes. The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs. A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression, working from caudally to cranially and medially to laterally, again using curettes and Kerrison rongeurs under direct visualization. In this manner, the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed. Local epidural veins were coagulated with bipolar and divided. Gelfoam was then placed in this area. This process was then repeated in similar fashion; thereby, exposing the posterolateral aspect of the left L5-S1 disk space. As noted, distraction had previously been placed at L4-L5, this was released. Distraction was placed across the L5-S1 interspace. After completing satisfactory exposure as noted, a annulotomy was made in the posterolateral left aspect of the L5-S1 disk space. Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure. The disk space was entered, and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate. Herniated portions of the disk were also removed in routine fashion. The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion. After completing this disk space preparation, Gelfoam was again placed. The decompression was assessed and appeared to be satisfactory. The distraction was released, and attention was redirected at L4-L5, where again, distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion. After completing the disk space preparation, attention was redirected to L5-S1. Distraction was released at L4-L5 and again, reapplied at L5-S1, incrementally increasing size. Trial spaces were used, and a 10-mm height by 26-mm length spacer was chosen. A medium BMP kit was appropriately reconstituted. A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space. The spacer was then carefully impacted into position. The distraction was released. The spacer was checked with satisfactory snugness and positioning noted. This process was then repeated in similar fashion at L4-L5, again with placement of a 10-mm height by 26-mm length Capstone spacer, again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace. This spacer was also checked again with satisfactory snugness and positioning noted. The prior placement of the spacers and BMP, the wound was thoroughly irrigated and dried with satisfactory hemostasis noted. Surgicel was placed over the exposed dura and disk space. The distraction was released on the right and compression plates across the L5-S1 and L4-L5 interspaces and the connections fully tightened in routine fashion. The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion, and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4-L5 and L5-S1 facets on the right in a routine fashion. A left-sided rod was appropriated contoured and placed to span between the L4 to S1 screws. Again compression was placed across the L4-L5 and L5-S1 segments, and these connections were fully secured. Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically. The wound was closed using multiple simple interrupted 0-Vicryl sutures to reapproximate the deep paraspinal musculature in the midline. The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0-Vicryl sutures. The suprafascial subcutaneous layers were closed using multiple simple interrupted #0 and 2-0 Vicryl sutures. The skin was then closed using staples. Sterile dressings were then applied and secured in place. The patient tolerated the procedure well and was to the recovery room in satisfactory condition.
## 101 TITLE OF OPERATION: ,Total thyroidectomy for goiter.,INDICATION FOR SURGERY: ,This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery. Risks, benefits, alternatives of the procedures were discussed in great detail with the patient. Risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other. The patient understood all these issues and they wished to proceed.,PREOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,POSTOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,ANESTHESIA: , General endotracheal.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine in a operating room table. After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube. The eyes were then tacked with Tegaderm. The Nerve Integrity monitoring system, endotracheal tube was confirmed to be working adequately. Essentially a 7 cm incision was employed in the lower skin crease of the neck. A 1% lidocaine with 1:100,000 epinephrine were given. Shoulder roll was applied. The patient prepped and draped in a sterile fashion. A 15-blade was used to make the incision. Subplatysmal flaps were raised to the thyroid notch and sternal respectively. The strap muscles were separated in the midline. As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side. The sternothyroid muscle was transected horizontally. Similar procedure was performed on the right side.,Attention was then turned to identify the trachea in the midline. Veins in this area and the pretracheal region were ligated with a harmonic scalpel. Subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe. Again this was very firm in nature. The superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel. The inferior and superior parathyroid glands were protected. Recurrent laryngeal nerve was identified in the tracheoesophageal groove. This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch. This was followed superiorly. The level of cricothyroid membrane upon complete visualization of the entire nerve, Berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea. A prominent pyramidal level was also appreciated and dissected as well.,Attention was then turned to the right side. There was significant amount of thyroid tissue that was very firm. Multiple nodules were appreciated. In a similar fashion, the capsule was dissected. The superior and inferior parathyroid glands protected and preserved. The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule. Once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery. The anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization. A small amount of tissue was left at the Berry's ligament as the remainder of thyroid level was dissected over the trachea. The entire thyroid specimen was then removed, marked with a stitch upon the superior pole. The wound was copiously irrigated, Valsalva maneuver was given, bleeding points controlled. The parathyroid glands appeared to be viable. Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system.,Attention was then turned to burying the Surgicel on the wound bed on both sides. The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated. The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon. The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin. The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle. The patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition. Upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.
## 102 PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1. Wound debridement x2, including skin, subcutaneous, and muscle.,2. Insertion of tissue expander to the medial wound.,3. Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA: ,General.,INDICATIONS: , This patient developed a compartment syndrome. She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg. She was doing very well and was obviously improving.,The swelling was reduced. A compartment pressure had obviously improved based on examination. She was therefore indicated for placement of tissue expander for ventral wound closure. The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well. Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. She understood them well. All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:, The patient was placed on the operating table and general anesthesia was achieved. The medial wound was noted to be approximately 10.5 cm in length x 4 cm. The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width. Both wounds were then thoroughly debrided. The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion. This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides. At this point adequate debridement was performed and healthy tissue did appear to be present. Initially on the medial wound I did place the DermaClose RC continuous external tissue expander. On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately. I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor. I then did place adequate tension on the sutures. Continued tension will be noted after engaging the tension controller. At this point I performed the similar procedure to the lateral wound. The skin anchors were placed separately and appropriately on either side of the skin margin. The line loop from the tension controller was placed in lace like manner through the skin anchors. The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained. Adequate tension was placed in this region. A non thick dressing was then applied to the open-wound region and sterile dressing was then applied. No complications were encountered throughout the procedure and the patient tolerated the procedure well. The patient was taken to recovery room in stable condition.
## 103 PREOPERATIVE DIAGNOSIS: , Thrombosed arteriovenous shunt left forearm.,POSTOPERATIVE DIAGNOSIS: ,Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,PROCEDURE: ,Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.,ANESTHESIA: , Local.,SKIN PREP: , Betadine.,DRAINS: , None.,PROCEDURE TECHNIQUE: ,The left arm was prepped and draped. Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop. The runoff vein was dissected out and encircled with the vessel loop as well. A longitudinal incision was made over the venous anastomosis. There was a narrowing in the area and slightly the incision was extended more proximally. There was good back bleeding from the vein as well as bleeding from the more distal vein. These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously. A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established. There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator. The Fogarty catheter was then passed up the vein, but no clot was obtained. A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture. Clamps were removed and flow established. A thrill was easily palpable. Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin. A sterile dressing was applied. The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct.
## 104 PREOPERATIVE DIAGNOSIS: ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:, Esophageal rupture.,OPERATION PERFORMED,1. Left thoracotomy with drainage of pleural fluid collection.,2. Esophageal exploration and repair of esophageal perforation.,3. Diagnostic laparoscopy and gastrostomy.,4. Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching. He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room. He was placed in a supine position on the operating table. After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll. Left chest was prepped and draped in a usual sterile fashion. After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace. The left lung was deflated and the pleural cavity entered. The Finochietto retractor was used to help provide exposure. The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid. Cultures of this were sampled and sent for microbiology analysis. The left pleural space was then copiously irrigated. A careful expiration demonstrated that the rupture appeared to be sealed. There was crepitus within the mediastinal cavity. The mediastinum was opened and explored and the esophagus was explored. The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus. It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area. The area was copiously irrigated, this provided nice coverage and repair. After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French. These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures. Muscle layers were closed with running #1 Vicryl sutures. The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position. A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed. A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced. The laparoscope was introduced. A single additional left-sided separator trocar was introduced. It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance. The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely. The skin incision was made and the gastric lumen was then accessed with the Seldinger technique. Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire. #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated. We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall. The T-fasteners were all crimped and secured into position. As was in the plan, the gastrostomy was secured to the skin and into the tube. Sterile dressing was applied. Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation. Radiographic gastrostomy tube study with gastric contrast, with
## 105 PREOPERATIVE DIAGNOSIS:, Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1. Right thoracotomy, total decortication.,2. Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDICATIONS FOR PROCEDURE: ,The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations. Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,OPERATIVE PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department. Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage. Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation. The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi. At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear. Bronchoscope was then removed. Vital signs remained stable throughout this portion of the procedure. The patient was re-intubated by Anesthesia with a double lumen endotracheal tube. At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion. At this point, the right chest was prepped and draped in the usual sterile fashion. The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine. The first port was placed through this incision intrathoracically. A bronchoscope was placed for inspection of the intrathoracic cavity. Pictures were taken. There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax. At this point, a second port site anteriorly was placed under direct visualization. With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid. Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped. Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion. Incision was made. The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space. The chest cavity was entered with the right lung deflated per Anesthesia at our request. Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe. With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand. There was no evidence of gross leakage or bleeding at the conclusion of surgery.,Full lung re-expansion was noted upon re-inflation of the lung. Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus. The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction. Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture. Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure. Steri-Strips were applied along with sterile occlusive dressings. The patient was awakened from anesthesia without difficulty and extubated in the operating room. The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung. The patient was transported to the recovery with vital signs stable. Stat portable chest x-ray is pending. The patient will be admitted to the Intensive Care Unit for close monitoring overnight.
## 106 POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube. Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle. The left groin, abdominal and chest were prepped and draped in a sterile fashion. A thoracoabdominal incision was made. The 8th interspace was entered. The costal margin was divided. The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta. The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm. It was dissected free circumferentially. The aortic bifurcation was dissected free, dissecting free both iliac arteries. The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this. The patient was heparinized. Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet. This was hooked to a venous inflow of left heart bypass machine. A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow. Bypass was instituted. The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm. The area was divided at this point. A 26-mm graft was then sutured in place with running 3-0 Prolene suture. The graft was brought into the diaphragm. Clamps were then placed on the iliacs, and the pump was shut off. The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation. The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch. The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference. The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels. The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture. All clamps were removed, and flow was re-established. An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal. A partial-occlusion clamp was placed. An area of graft was removed. The end of the graft was cut to fit this and sutured in place with running Prolene suture. The partial-occlusion clamp was removed. Protamine was given. Good hemostasis was noted. The arterial cannula, of course, had been removed when that part of the aneurysm was removed. The venous cannula was removed and oversewn with a 4-0 Prolene suture. Good hemostasis was noted. A 36 French posterior and a 32 French anterior chest tube were placed. The ribs were closed with figure-of-eight #2 Vicryl. The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch. Patient tolerated the procedure well.
## 107 PREOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,POSTOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,PROCEDURE: , Left thoracotomy with total pulmonary decortication and parietal pleurectomy.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube. A time-out process had been followed and preoperative antibiotics were given.,The patient was positioned with the left side up for a left thoracotomy. The patient was prepped and draped in the usual fashion. A posterolateral thoracotomy was performed. It included the previous incision. The chest was entered through the fifth intercostal space. Actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke. Thanks to Dr. X's ingenuity, we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura. We aspirated an abundant amount of pus from this cavity. The sample was taken for culture and sensitivity.,Then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm. Once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung. Further samples for culture and sensitivity were sent.,Then, we were left with the trapped lung. It was trapped by thickened visceral pleura. This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively. Finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily. There was only one area towards the mediastinum that apparently I was not able to fill. This area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so I restrained from doing that. Two large chest tubes were placed. The cavity had been abundantly irrigated with warm saline. Then, the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.,The chest tubes were affixed to the skin with heavy sutures of silk. Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.,Estimated blood loss was about 500 mL. The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition.
## 108 PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1. Left thoracoscopy.,2. Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:, Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION: ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray. Preoperative evaluation included a CT scan, which showed focal mass. CT and PET confirmed anterior lesion. Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction. In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly. She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty. She was sedated and intubated with double-lumen endotracheal tube without difficulty. She was positioned with left side up. Appropriate pressure points were padded. The left chest was prepped and draped in the standard surgical fashion. The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered. There was good deflation of the left lung. __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning. Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall. There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified. The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm. It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion. Camera was placed through this port. Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity. Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site. This was taken down to the subcutaneous tissue with Bovie electrocautery. Periosteal elevator was used to lift the intercostal muscle off. The ribs were not spread. Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed. Prestige graspers were used to pull the specimen from the chest wall. Care was taken not to injure the capsule. The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall. Care was taken not to transect the stalk. Specimen came off the chest wall very easily. There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision. Specimen was placed in the bag and then removed from the field. There was good hemostasis. Camera was removed. A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture. The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes. The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.
## 109 PREOPERATIVE DIAGNOSES:,1. Thrombosed left forearm loop fistula graft.,2. Chronic renal failure.,3. Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1. Thrombosed left forearm loop fistula graft.,2. Chronic renal failure.,3. Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:, The venous outflow was good. There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft. She was not able to have her dialysis as routine. Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery. Both Surgery and Anesthesia thought this would be too risky to do. Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning. This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion. A transverse incision was made at the region of the venous anastomosis of the graft. Further dissection was carried down to the catheter. The vein appeared to be soft and without thrombus. This outflow did not appear to be significantly impaired. A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis. Next, a thrombectomy was done using a #4 Fogarty catheter. Some of the clot and thrombus was removed from the venous limb. The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis. Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis. At this point, we felt the patient would benefit from a curettage of the venous limb of the graft. This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage. The Fogarty balloon was then passed beyond the clot and the plug. The plug was visualized and inspected. This also gave a good brisk bleeding from the graft. The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb. Attention was directed up to its anastomosis and the vein. Fogarty balloon and thrombectomy was also performed well enough into this way. There was good venous back bleeding following this. The area was checked for any stenosis with the dilators and none was present. Next, a #6-0 Prolene suture was used in a running fashion to close the graft. Just prior to tying the suture, the graft was allowed to flush to move any debris or air. The suture was also checked at that point for augmentation, which was good. The suture was tied down and the wound was irrigated with antibiotic solution. Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges. Steri-Strips were applied and the patient was taken to recovery in stable condition. She tolerated the procedure well. She will be discharged from recovery when stable. She is to resume her regular dialysis schedule and present for dialysis tomorrow.
## 110 PREOPERATIVE DIAGNOSES:, Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:, Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:, General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax. There was also noted to be some mild infiltrates of the right lung. The patient had a 30-year history of cigarette smoking. A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor. Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT. The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed. The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out. This was suctioned out with the addition of the use of saline ***** in the bronchus. Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment. Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted. These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus. Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that. The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract. A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity. Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout. Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe. There were many pockets of purulent material, which had a gray-white appearance to it. There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe. The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time. There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed. Many cultures were taken from several areas. The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:, With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner. The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this. Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy. Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space. Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity. Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense. Suture ligatures of Prolene were required. When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a "tissue pledget" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed. The patch was sutured onto the pulmonary artery tear. A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity. Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel. After reasonably good hemostasis was established pleural cavity was irrigated with saline. As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung. Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk. One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex. These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed. Sponge count was reported as being correct. Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out. Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib. Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl. The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin. The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure. Sterile dressings were applied. The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen. The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.
## 111 PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. She has failed conservative measures and sought operative intervention for relief of her symptoms. For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION: ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic. She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected. Second check was made prior to prepping and draping. Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level. We then made an approach through a midline incision and came out over the pars. We dissected down carefully to identify the pars. We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level. We did this under live fluoroscopy. We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well. We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars. The pars was then drilled out. We identified the disc even further and found the disc herniation material that was under the spinal cord. We then took a combination of small pituitaries and removed the disc material without difficulty. Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further. Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well. We could trace the nerve root out freely and easily. We made sure there was no evidence of further disc material. We used an Epstein curette and placed a nerve hook under the nerve root. The Epstein curette removed some more disc material. Once we had done this, we were satisfied with the decompression. We irrigated the wound copiously to make sure there is no further disc material and then ready for closure. We did place some steroid over the nerve root and readied for closure. Hemostasis was meticulous. The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied. Dressing was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 150 mL.,COMPLICATIONS: , None.,DISPOSITION:, To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.
## 112 PREOPERATIVE DIAGNOSIS:, Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS: ,Rule out temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsy.,ANESTHESIA:, Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:, I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis. I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way. After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery. The temporal artery was identified and was grossly normal on both sides. Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult. The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm. They were sent as separate specimens, right and left labeled. The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond. She tolerated the procedure well.
## 113 PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE: ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room. After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion. Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line. Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall. Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid. From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle. At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine. At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation. We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,
## 114 OPERATION,1. Insertion of a left subclavian Tesio hemodialysis catheter.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered. Next, the patient's chest and neck were prepped and draped in the standard surgical fashion. Lidocaine 1% was used to infiltrate the skin in the region of the procedure. Next a #18-gauge finder needle was used to locate the left subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle. This process was repeated. The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, the subcutaneous tunnel was created. The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff. A dilator and sheath were passed over the individual J wires. The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn. The process was repeated. Both distal tips were noted to be in good position. The Tesio hemodialysis catheters were flushed and aspirated without difficulty. The catheters were secured at the cuff level with a 2-0 nylon. The skin was closed with 4-0 Monocryl. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition.
## 115 PREOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion. Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly. The temporal artery was found and exposed in an extension of about 2 cm. The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology. Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion. A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm. This was also proximally and distally ligated with 6-0 Prolene and also side branch. Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well. Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.
## 116 PREOPERATIVE DIAGNOSIS:, Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:, Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:, General, oral endotracheal tube.,COMPLICATIONS: , None.,SPECIMENS:, Aerobic and anaerobic cultures were sent.,IV FLUID: , 150 mL.,ESTIMATED BLOOD LOSS:, 10 mL.,PROCEDURE: , The patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure. Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located. The abscess cavity was aspirated using a 5 mL syringe with an 18-gauge needle. Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures. Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,The area in the buccal vestibule was then opened with approximately 1-cm incision. Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity. A small amount of additional purulence was drained from it, approximately 1 mL and at this point, tooth #T was extracted by forceps extraction. Periosteal elevator was used to explore the area near the extraction site. This was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site. No drain was placed. Upon completion of the procedure, the throat pack was removed. The pharynx was suctioned. The stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.
## 117 OPERATIONS/PROCEDURES,1. Insertion of right internal jugular Tessio catheter.,2. Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The right neck, chest and left arm were prepped and draped in a sterile fashion. A small incision was made at the top of the anterior jugular triangle in the right neck. Through this small incision, the right internal jugular vein was punctured and a guidewire was placed. It was punctured a 2nd time, and a 2nd guidewire was placed. The Tessio catheters were assembled. They were measured for length. Counter-incisions were made on the right chest. They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs. They were flushed with saline. A suture was placed through the guidewire, and the guidewire and dilator were removed. The arterial catheter was then placed through this, and the tear-away introducer was removed. The catheter aspirated and bled easily. It was flushed with saline and capped. This was repeated with the venous line. It also aspirated easily and was flushed with saline and capped. The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon. Dressings were applied. An incision was then made at the left wrist. The basilic vein was dissected free, as was the radial artery. Heparin was given, 50 mg. The radial artery was clamped proximally and distally with a bulldog. It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed. The vein was clipped distally, divided and spatulated for anastomosis. It was sutured to the radial artery with a running 7-0 Prolene suture. The clamps were removed. Good flow was noted through the artery. Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin. The patient tolerated the procedure well.
## 118 PREOPERATIVE DIAGNOSIS:, Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:, After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. His left back was prepped and draped in the usual fashion. Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood. This blood was nonclotting and it was tested twice. Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s. Therefore, we laid him off his right side while keeping the chest catheter in place. At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.
## 119 PREOPERATIVE DIAGNOSES: , Carious teeth #2 and #19 and left mandibular dental abscess.,POSTOPERATIVE DIAGNOSES:, Carious teeth #2 and #19 and left mandibular dental abscess.,PROCEDURES:, Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,ANESTHESIA: , General, oral endotracheal.,COMPLICATIONS: , None.,DRAINS: , Penrose 0.25 inch intraoral and vestibule and extraoral.,CONDITION:, Stable to PACU.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure. In addition, the extraoral area on the left neck was prepped with Betadine and draped accordingly. Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant, total of 3.4 mL of lidocaine 2% with 1:100,000 epinephrine and Marcaine 1.7 mL of 0.5% with 1:200,000 epinephrine. An incision was made with #15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible. No purulent drainage was obtained. The 0.25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3-0 silk suture. Moving to the intraoral area, periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth #19. The area did not drain any purulent material. The carious tooth #19 was then extracted by elevator and forceps extraction. After the tooth was removed, the 0.25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3-0 silk suture. The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth #2 was then extracted by routine elevator and forceps extraction. After the extraction, the throat pack was removed. An orogastric tube was then placed by Dr. X, and stomach contents were suctioned. The pharynx was then suctioned with the Yankauer suction. The patient was awakened, extubated, and taken to the PACU in stable condition.
## 120 PREOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS: ,Zero.,SPECIMENS: ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room. After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery. Routine prep and drape was employed. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure. Hand was positioned palm up in the lead hand-holder. A short curvilinear incision about the base of the thenar eminence was made. Skin was sharply incised. Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin. Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm. Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve. Retinacular flap was retracted radially to expose the contents of the carpal canal. Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing. Locally adherent tenosynovium was present and this was carefully dissected free. Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal. Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium. When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures. A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort. Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home. Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n. Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery. She was asked to keep the dressings clean, dry and intact and follow up in my office.
## 121 PREOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1. Partial tarsectomy navicula, right foot.,2. Partial metatarsectomy, right foot.,HISTORY: ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time.,PROCEDURE: ,An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered as well as the operating table. The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. Attention was then directed to the navicular region on the right foot. The area was palpated until the bony prominence was noted. A curvilinear incision was made over the area of bony prominence. At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site. The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. The dissection was carried down to the level of the capsule and periosteum. A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. The periosteum and the capsule were then reflected from the navicular bone at this time. A bony prominence was noted both medially and plantarly to the navicular bone. An osteotome and mallet were then used to resect the enlarged portion of the navicular bone. After resection with an osteotome there was noted to be a large plantar shelf. The surrounding soft tissues were then freed from this plantar area. Care was taken to protect the attachments of the posterior tibial tendon as much as possible. Only minimal resection of its attachment to the fiber was performed in order to expose the bone. Sagittal saw was then used to resect the remaining plantar medial prominent bone. The area was then smoothed with reciprocating rasp until no sharp edges were noted. The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted. The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl. The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal. There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. The incision was then deepened with #15 blade. Care was taken to preserve the extensor tendon. The incision was then created over the capsule and periosteum of the fifth metatarsal head. Capsule and periosteum were reflected both dorsally, laterally, and plantarly. At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp. The area was inspected for the remaining bony prominences and none was noted. The area was flushed with copious amounts of sterile saline. The capsule and periosteum were then reapproximated with #3-0 Vicryl. Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line. Running #5-0 subcutaneous stitch was then performed. Steri-Strips were applied to both surgical sites. Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred to the PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.
## 122 PREOPERATIVE DIAGNOSES,1. Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2. Left mandibular vestibular abscess.,POSTOPERATIVE DIAGNOSES,1. Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2. Left mandibular vestibular abscess.,PROCEDURE,1. Extraction of teeth #2. #5, #12, #15, #18, #19, #31.,2. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,ANESTHESIA:, General nasotracheal.,COMPLICATIONS: , None.,DRAIN:, Quarter-inch Penrose drain place in left mandibular vestibule adjacent to teeth #18 and #19, secured with 3-0 silk suture.,CONDITION:, The patient was taken to the PACU in stable condition.,INDICATION:, Patient is a 32-year-old female who was admitted yesterday 03/04/10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning, the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure. A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 6.8 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of Marcaine 0.5% with 1:200,000 epinephrine. The area in the left vestibular area adjacent to the teeth #18 and #19 was aspirated with 5 cc syringe with an 18-guage needle and approximately 1 mL of purulent material was aspirated. This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab. An incision was then made in the left mandibular vestibule adjacent to teeth #18 and #19. The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained. Penrose drain was then placed using a curved hemostat. The drain was secured with 3-0 silk suture. The extraction of the teeth was then begun on the left side removing teeth #12, #15, #18 and #19 with forceps extraction, then moving to the right side teeth #2, #5, and #31 were removed with forceps extraction uneventfully. After completion of the procedure, the throat pack was removed, the pharynx was suctioned. The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube. The nasogastric tube was then removed. Patient was then extubated and taken to the PACU in stable condition.
## 123 PREOPERATIVE DIAGNOSES,1. Basal cell nevus syndrome.,2. Cystic lesion, left posterior mandible.,3. Corrected dentition.,4. Impacted teeth 1 and 16.,5. Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1. Basal cell nevus syndrome.,2. Cystic lesion, left posterior mandible.,3. Corrected dentition.,4. Impacted teeth 1 and 16.,5. Maxillary transverse hyperplasia.,PROCEDURE,1. Removal of cystic lesion, left posterior mandible.,2. Removal of teeth numbers 4, 13, 20, and 29.,3. Removal of teeth numbers 1 and 16.,4. Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome. Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position. Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures. The oral cavity was suctioned, was drained of fluid and a throat pack was placed. General anesthesia nursing service was notified and which was removed at the end of the procedure. Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL. A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth. Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt. Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle. Secondly, tooth number 4 was removed. Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side. Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9. This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion. These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure. Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar. The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle. This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin. Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure. Teeth number 20 and 29 where removed and 3-0 chromic suture placed. This concluded the procedure. All cottonoids and other sponges, throat pack were removed. No complications were encountered. The aforementioned cystic lesion was sent with specimen no drains were placed. The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.
## 124 PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:, Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:, The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery. The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth. After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1. Methadone.,2. Beta-blocker.,3. Xanax.,4. Norco.,5. Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present. The patient was prepped and draped in sterile fashion. Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible. Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered. Extraction sites were thoroughly curettaged and irrigated. Bony undercuts were removed then smoothed with rongeurs and bone saw. After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures. Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions. Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged. Wound was closed in continuous fashion 3-0 chromic. After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control. Total of 8 mL were used. Throat pack was subsequently removed. Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery. The patient would be placed in 23-hour observation.
## 125 PREOPERATIVE DIAGNOSIS: ,Persistent abnormal uterine bleeding after endometrial ablation.,POSTOPERATIVE DIAGNOSIS: , Persistent abnormal uterine bleeding after endometrial ablation.,PROCEDURE PERFORMED: , Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 250 cc.,FLUIDS: ,1500 cc of crystalloids.,URINE: , 125 cc of clear urine at the end of the procedure.,FINDINGS: , On exam, under anesthesia, an obese female with an enlarged fibroid uterus freely movable on the pelvis. Operative findings demonstrated the same with normal appearing tubes bilaterally. The right ovary contained a right ovarian cyst. The left ovary appeared to be within normal limits. The peritoneal surfaces were noted to be within normal limits. The bowel was also noted to be within normal limits.,INDICATIONS FOR THIS PROCEDURE: , The patient is a 44-year-old female who had an endometrial ablation done in May, which showed submucosal fibroids. She had history of anemia and has been on iron therapy. She started having bleeding three weeks ago with intermittent bouts of flooding.,She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy. The uterus, cervix, and right tube and ovary was sent to pathology for review.,PROCEDURE: , After informed consent was obtained, all questions were answered to the patient's satisfaction in layman's term. She was taken to the operating room where a general anesthesia was obtained without any difficulty. She was examined under anesthesia with noted findings above. She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion. The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia. With the second knife, the fascia was excised in the midline and extended laterally with the Mayo scissors. The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly. Attention was then turned to the inferior aspect of the fascial incision, which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly. The rectus muscle was then separated in the midline, the peritoneum was identified, entered bluntly and digitally. Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder. The GYN Balfour was then placed. A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges. Attention was then turned to the round ligaments bilaterally, which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the #O-tie was passed through and then tied down. Then the round ligament was transected and suture ligated and noted to be hemostatic. The round ligaments were then skeletonized to create a window in the broad ligament. The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion. It was noted to be hemostatic. Attention was then turned to the left side, in which the uterovarian vessel was isolated and then tied with an #O-tie and then doubly clamped with straight Ochsner clamps, transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion and noted to be hemostatic. The vesicouterine peritoneum was then identified, tented up with Allis clamps, and then the bladder flap was created sharply with a Russian and Metzenbaum scissors. Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray-Tec sponge down to the level of the cervix.,The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic. In the similar fashion, the broad ligament down to the level of the caudal ligament, the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated, and noted to be hemostatic. The second Lahey clamp was then placed on the cervix. The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable. The cuff was then outlined. The vaginal cuff was grasped with a Ochsner clamp and then the cervix, uterus, and the right tube and ovary were transected using the Jorgenson scissors. The cuff outlined with Ochsner clamps. The cuff was then painted with a Betadine soaked Ray-Tec sponge and the sponge was placed over the vagina. The vaginal cuff was then closed with a #0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles. A long Allis was then used to grasp the mid portion of the cuff and a #0 Vicryl figure-of-eight stitch was placed in the mid portion of the cuff and tied down. At this time, the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic. The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff, and then tied down to bring the cuff close and together. Then, the right round ligament was pulled into the cuff and tied down with the #0 Vicryl that was used as a figure-of-eight stitch in the middle of the cuff. The left round ligament was too small to reach the cuff. The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic. The peritoneum was then re-peritonealized with a #3-0 Vicryl in a running fashion. The GYN Balfour and all packing sponges were removed from the abdomen. Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic. The ______ was placed back into the hollow of the sacrum. The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a #3-0 Vicryl in a running fashion and then the fascia was closed with #0 Vicryl in a running fashion. The skin was closed with staples and dressing applied. The patient was then examined at the end of the procedure. The Betadine-soaked sponge was removed from the vagina. The cuff was noted to be intact without bleeding and the patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2 and she was taken to the recovery in stable condition. The patient will be followed throughout her hospital stay.
## 126 PREOPERATIVE DIAGNOSES:,1. Cervical intraepithelial neoplasia grade-III status post conization with poor margins.,2. Recurrent dysplasia.,3. Unable to follow in office.,4. Uterine procidentia grade II-III.,POSTOPERATIVE DIAGNOSES:,1. Cervical intraepithelial neoplasia grade-III postconization.,2. Poor margins.,3. Recurrent dysplasia.,4. Uterine procidentia grade II-III.,5. Mild vaginal vault prolapse.,PROCEDURES PERFORMED:,1. Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy.,2. Uterosacral ligament vault suspension.,ANESTHESIA: , General and spinal with Astramorph for postoperative pain.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,FLUIDS: ,2400 cc.,URINE: , 200 cc of clear urine output.,INDICATIONS: ,This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,FINDINGS: ,On bimanual examination, the uterus was found to be small. There were no adnexal masses appreciated. Intraabdominal findings revealed a small uterus approximately 2 cm in size. The ovaries were atrophic consistent with menopause. The liver margins and stomach were palpated and found to be normal.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control. She was then placed in the dorsal lithotomy position and administered general anesthesia. She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder. At this point, the patient was evaluated for a possible vaginal hysterectomy. She was nulliparous and the pelvis was narrow. After the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy. After the patient was prepped and draped, a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis. The second scalpel was used to dissect out to the underlying layer of fascia. The fascia was incised in the midline and extended laterally using the Mayo scissors. The superior aspect of the rectus fascia was grasped with Ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors. In a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with Mayo scissors. The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum. The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder. At this point, the above findings were noted and the GYN Balfour retractor was placed. Moist laparotomy sponges were used to pack the bowel out of the operative field. The bladder blade and the extension for the retractor were then placed. An Allis was used on the uterus for retraction. The round ligaments were then identified, clamped with two hemostats and transected and then suture ligated. The anterior portion of the broad ligament was dissected along vesicouterine resection. The bladder was then dissected off the anterior cervix and vagina without difficulty. The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 Vicryl suture. The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 Vicryl. Good hemostasis was assured. The cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 Vicryl. Good hemostasis was obtained. Two hemostats were then placed just under the cervix meeting in the midline. The uterus and cervix were then _______ off using a scalpel. This was handed and sent to Pathology for evaluation. Using #0 Vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament. A baseball stitch was then used to close the cuff to the midline. The same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments. The baseball stitch was used to close the cuff to the midline. The hemostats were removed and the cuff was closed and good hemostasis was noted. The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff. The pelvis was then copiously irrigated with warm normal saline. Good support and hemostasis was noted. The bowel packing was then removed and the GYN Balfour retractor was moved. The peritoneum was then repaired with #0 Vicryl in a running fashion. The fascia was then closed using #0 Vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion. The skin was then closed with #4-0 undyed Vicryl in a subcuticular closure and an Op-Site was placed over this. The patient was then brought out of general anesthesia and extubated. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. She will follow up postoperatively as an inpatient.
## 127 PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Endometriosis.,3. Prior right salpingo-oophorectomy.,4. History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1. Endometriosis.,2. Interloop bowel adhesions.,PROCEDURE PERFORMED:,1. Total abdominal hysterectomy (TAH).,2. Left salpingo-oophorectomy.,3. Lysis of interloop bowel adhesions.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions. On bimanual exam, the uterus was enlarged, movable, and anteverted. The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation. The uterus was found to be normal in size with evidence of endometriosis on the uterus. The right ovary and fallopian tube were absent. The left fallopian tube and ovary appeared normal with evidence of a small functional cyst. There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected. There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent. There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis. She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy. She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia. She was then prepped and draped in the sterile fashion and placed in the dorsal supine position. An indwelling Foley catheter was placed. With the skin knife, an incision was made removing the old cicatrix. A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie. The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie. The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly. The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder. At this point, the intraabdominal cavity was manually explored and the above findings were noted. A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field. The bowel was then packed with moist laparotomy sponges. Prior to this, the filmy adhesions leftover were taken down. At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl. At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created. The posterior aspect of the peritoneum was also dissected. At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle. Two hemostats were then placed across the pedicle and this was transected with the scalpel. This was then suture ligated in Heaney fashion. The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament. This was then ligated with three tie of #0 Vicryl. Also incorporated in this was the remnant from the previous right salpingo-oophorectomy. At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed. In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed. These ligaments bilaterally were transected and suture ligated in a left Heaney stitch. At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated. Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated. Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl. At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix. The roticulator was then clamped and removed and the staple line was in place. This was found to be hemostatic. A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally. At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum. There did appear to be good support on palpation. Prior to this, the specimen was handed off and sent to pathology. At this point, there did appear to be small amount of oozing at the right peritoneum. Hemostasis was obtained using a #0 Vicryl in two single stitches. Good hemostasis was then obtained on the cuff as well as the pedicles. Copious irrigation was performed at this point with lactate Ringers. The round ligaments were then incorporated into the cuff bilaterally. Again, copious amount of irrigation was performed and good hemostasis was obtained. At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally. At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel. Good hemostasis was obtained of these sites as well. The sigmoid colon was then returned to its anatomic position and the omentum as well. The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl. The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline. The Scarpa's fascia was then closed with #3-0 plain in a running suture. The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure. This was dressed with an Op-Site. The patient tolerated the procedure well. The sponge, lap, and needle were correct x2. After the procedure, the patient was extubated and brought out of general anesthesia. She will go to the floor where she will be followed postoperatively in the hospital.
## 128 PREOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,OPERATION PERFORMED: , Arthroscopic irrigation and debridement of same with partial synovectomy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,DRAINS:, None.,INDICATIONS:, The patient is an 81-year-old female, who is approximately 10 years status post total knee replacement performed in another state, who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection. The patient' knee was aspirated in the office and cultures were positive for Escherichia coli. She presents for operative therapy.,DESCRIPTION OF OPERATION: , After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained, the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position. The left upper extremity was prepped and draped without a tourniquet. The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created. The arthroscopy was inserted and a complete diagnostic was performed. Arthroscopic pictures were taken throughout the procedure. The knee was copiously irrigated with 9 L of irrigant. A partial synovectomy was performed in all compartments. Minimal amount of polyethylene wear was noted. The total knee components were identified arthroscopically for future revision surgery. The knee was then drained and the arthroscopic instruments were removed. The portals were closed with 4-0 nylon and local anesthetic was injected. A sterile dressing was applied and the patient was placed in a knee immobilizer, awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well.
## 129 PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,PROCEDURES PERFORMED: ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:, Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:, A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw. A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position. At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis. Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site. The right foot was then scrubbed, prepped, and draped in the usual aseptic manner. An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg. Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made. The incision was carried deep utilizing both sharp and blunt dissections. All major neurovascular structures were avoided. At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified. This was then incised fully exposing the tendon and the abductor hallucis muscle. This was then resected from his osseous attachments and a small tenotomy was performed. At this time, a small lateral capsulotomy was also performed. Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision. The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field. A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye. The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position. The dorsal arm was made longer than the plantar arm to accommodate for fixation. At this time, the capital fragment was resected and shifted laterally into a more corrected position. At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation. Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site. Compression was noted to be excellent. All guide wires and 0.045-inch K-wires were then removed. Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field. The wound was then once again flushed with copious amounts of sterile normal saline. At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated. At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon. At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension. Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal. Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field. Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head. The head was then shifted medially into a more corrected position. A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site. This was noted to be in correct position and compression was noted to be excellent. Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field. The wound was once again flushed with copious amounts of sterile normal saline. The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon. At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site. The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion. The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot. The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot. After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A. The patient is to be nonweightbearing to the right foot. The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these. The patient tolerated the procedure and anesthesia well. Dr. A was present throughout the entire case.
## 130 PREOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Uterine fibroids.,3. Pelvic pain.,4. Left adnexal mass.,5. Pelvic adhesions.,POSTOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Uterine fibroids.,3. Pelvic pain.,4. Left adnexal mass.,5. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Total abdominal hysterectomy (TAH).,2. Left salpingo-oophorectomy.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,INDICATIONS: , The patient is a 47-year-old Caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003. The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.,FINDINGS AT THE TIME OF SURGERY: , Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.,On laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass. The bowel, omentum, and appendix had a normal appearance.,PROCEDURE: , The patient was taken to the operative suite where anesthesia was found to be adequate. She was then prepared and draped in normal sterile fashion. A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel. The fascia was then incised in the midline. The fascial incision was then extended laterally with Mayo scissors. The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors. Attention was then turned to the inferior aspect of this incision, which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors. The rectus muscle was then separated in the midline. The peritoneum was identified, tented up with hemostats and entered sharply with Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder. The uterus and left adnexa were then palpated and brought out into the surgical field. The fundus of the uterus was grasped with a Lahey clamp. The GYN/Balfour retractor was placed. The bladder blade was placed. The bowel was packed away with moist laparotomy sponges and the extension through GYN/Balfour retractor was placed. At this time, the patient's anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass. Attention was first turned to the right round ligament, which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat. It was then suture ligated with #0 Vicryl suture, transected with the broad ligament being skeletonized on both sides. Next, the right ________ was isolated bluntly as the patient had a previous RSO. This was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, transected, and suture ligated with #0 Vicryl suture with a Heaney stitch. Attention was then turned to the left round ligament, which was tented up with the Babcock. Small window was made beneath it and the broad ligament with hemostat was then suture ligated with #0 Vicryl suture, transected, and skeletonized with the aid of Metzenbaums. The left infundibulopelvic ligament was then bluntly isolated. It was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, and transected and suture ligated with #0 Vicryl suture with a Heaney stitch. The bladder flap was then placed on tension with Allis clamps. It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians. It was then gently pushed off of lower uterine segment with the aid of a moist Ray-Tec. The uterine arteries were then skeletonized bilaterally.,They were then clamped with straight Kocher clamps, transected, and suture ligated with #0 Vicryl suture. The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps. These were then transected and suture ligated with #0 Vicryl suture. The lower uterine segment was then grasped with Lahey clamps, at which time the cervix was already visible. It was then entered with the last transection. The cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of Jorgenson scissors. The angles of the vaginal cuff were then grasped with Kocher clamps. A Betadine-soaked Ray-Tec was then pushed into the vagina and the vaginal cuff was closed with #0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed. Good hemostasis was appreciated. A figure-of-eight suture in the center of the vaginal cuff was placed with #0 Vicryl. This was tagged for later use. The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 Vicryl suture. The round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place. The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated. The peritoneal surfaces were then reapproximated with the aid of #3-0 Vicryl suture in a running fashion. The GYN/Balfour retractor and bladder blade were then removed. The bowel was then packed. Again copious suction irrigation was performed with hemostasis appreciated. The peritoneum was then reapproximated with #2-0 Vicryl suture in a running fashion. The fascia was then reapproximated with #0 Vicryl suture in a running fashion. The Scarpa's fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a subcuticular fashion. Steri-Strips were placed. At the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally. The patient tolerated the procedure well and was taken to Recovery in stable condition. Sponge, lap, and needle counts were correct x2. Specimens include uterus, cervix, left fallopian tube, and ovary.
## 131 PROCEDURES:,1. Placement of SynchroMed infusion pump.,2. Tunneling of SynchroMed infusion pump catheter,3. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position. The patient was prepped and draped in a sterile manner. The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter. This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle. A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle. The needle was withdrawn. The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak. The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure. The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene. Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created. Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery. A pocket was created that would encompass the SynchroMed fusion pump. A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device. The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision. The intrathecal catheter was trimmed. A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together. The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties. Good CSF was then demonstrated flowing through the SynchroMed pump catheter. The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie. Excess catheter was coiled and placed behind the pump. The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall. The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed. The subcutaneous tissues were irrigated with normal saline. The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl. The skin of both wounds was closed with staples. Antibiotic ointment and a sterile dressing were applied. The patient was awake and taken to the recovery room. The patient tolerated the procedure well and was stable at the completion of the procedure. All sponge and lap, needle and instrument counts were correct at the completion of the procedure.
## 132 PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Dysmenorrhea.,3. Dyspareunia.,4. Endometriosis.,5. Enlarged uterus.,6. Menorrhagia.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Dysmenorrhea.,3. Dyspareunia.,4. Endometriosis.,5. Enlarged uterus.,6. Menorrhagia.,PROCEDURE: , Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,DRAINS: , Foley.,ANESTHESIA:, General.,This 28-year-old white female who presented to undergo TAH-BSO secondary to chronic pelvic pain and a diagnosis of endometriosis.,At the time of the procedure, once entering into the abdominal cavity, there was no gross evidence of abnormalities of the uterus, ovaries or fallopian tube. All endometriosis had been identified laparoscopically from a previous surgery. At the time of the surgery, all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed in supine position, at which time general form of anesthesia was administered by the anesthesia department. The patient was then prepped and draped in the usual fashion for a low transverse incision. Approximately two fingerbreadths above the pubic symphysis, a first knife was used to make a low transverse incision. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in a transverse fashion. The edges of the fascia were grasped with Kocher. Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique. The abdominal rectus muscle was divided in the midline and extended in a vertical fashion. Perineum was entered at the high point and extended in a vertical fashion as well. An O'Connor-O'Sullivan retractor was put in place on either side. A bladder blade was put in place as well. Uterus was grasped with a double-tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade. The bladder flap was released with Metzenbaum scissors and then dissected away caudally. EndoGIA were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium Endoclip. Two Heaney were placed on either side of the uterus at the level of cardinal ligaments. These were sharply incised and both pedicles were tied off with 1 Vicryl suture. Two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault. A long sharp knife was used to transect the uterus at the level of Merz forceps and the uterus and cervix were removed intact. From there, the corners of the vaginal cuff were reinforced with figure-of-eight stitches. Betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 Vicryl was used to re-approximate the edges with a second layer used to reinforce the first. Bladder flap was created with the use of 3-0 Vicryl and Gelfoam was placed underneath. The EndoGIA was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips. The entire area was then re-peritonized and copious amounts of saline were used to irrigate the pelvic cavity. Once this was completed, Gelfoam was placed into the cul-de-sac and the O'Connor-O'Sullivan retractor was removed as well as all the wet lap pack. Edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2-0 Vicryl was used to re-approximate the peritoneum as well as abdominal rectus muscle. The edges of the fascia were grasped at both corners and a continuous locking stitch of 1 Vicryl was used to re-approximate the fascia with overlapping in the center. The subcutaneous tissue was irrigated. Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the tissue and the skin edges were re-approximated with sterile staples. Sterile dressing was applied and Betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood. The patient was taken to recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct.
## 133 PREOPERATIVE DIAGNOSIS: , Missed abortion.,POSTOPERATIVE DIAGNOSIS: ,Missed abortion.,PROCEDURE PERFORMED: , Suction, dilation, and curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:, 50 mL.,COMPLICATIONS: , None.,FINDINGS: , Products of conception consistent with a 6-week intrauterine pregnancy.,INDICATIONS: , The patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today. A workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy. No heart tones were visible. On examination in the emergency room, a moderate amount of bleeding was noted.,Additionally, the cervix was noted to be 1 cm dilated. These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient. After discussion of these options, the patient opted for a suction, dilation, and curettage. The patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation. Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE: ,The patient was taken to the operating room where spinal anesthesia was administered without difficulty. The patient was prepped and draped in usual sterile fashion in lithotomy position. A weighted speculum was placed. The anterior lip of the cervix was grasped with a single tooth tenaculum. At this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus. Following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted. At this time, the suction curette was advanced one additional time to suction any remaining products. All instruments were removed. Hemostasis was visualized. The patient was stable at the completion of the procedure. Sponge, lap, and instrument counts were correct.
## 134 PREOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1. Excision of mass, left second toe.,2. Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:, An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap. Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses. The foot was lowered to the operating table. The stockinet was reflected and the foot was cleansed with wet and dry sponge. A distal Syme's incision was planned over the distal aspect of the left hallux. The incision was performed with a #10 blade and deepened with #15 down to the level of bone. The dorsal skin flap was removed and dissected in toto off of the distal phalanx. There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx. The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer. Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen. At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx. The area was inspected for any remaining suspicious tissues. Any suspicious tissue was removed. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe. There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe. A linear incision was made just medial to the tissue mass. The mass was then dissected from the overlying skin and off of the underlying capsule. This tissue mass was hard, round, and pearly-gray in appearance. It does not invade into any other surrounding tissues. The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon. Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed. The patient will be contacted immediately pending the results of pathology. Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
## 135 PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties. Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy. The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure. He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection. The tract and the stomach were freed. Stay sutures were then placed on either side of the tract. The tract was amputated. The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures. The fascia was then closed over the stomach using #3-0 Vicryl sutures. The skin was closed with #5-0 subcuticular Monocryl. A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.
## 136 OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied.
## 137 PREOPERATIVE DIAGNOSIS:, Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3.,POSTOPERATIVE DIAGNOSIS: , Right buccal and canine's base infection from necrotic teeth. ICD9 Code: 528.3.,PROCEDURE: , Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.,SPECIMENS: , Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,DRAINS: ,A 1.5 inch Penrose drain placed in the right buccal and canine space.,ESTIMATED BLOOD LOSS:, 40 Ml.,FLUID: ,700 mL of crystalloid.,COMPLICATIONS: ,None.,CONDITION: ,The patient was extubated breathing spontaneously to the PACU in good condition.,INDICATION FOR PROCEDURE: ,The patient is a 41-year-old that has a recent history of toothache and tooth pain. She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions. The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment. She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse. The patient was admitted to the hospital on Monday for IV antibiotics. Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain. The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery. It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia. Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room and laid on the operating room table on supine fashion. ASA monitors were attached as stated. General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in usual oromaxillary facial surgery fashion.,An 18-gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space. This pus was then cultured and sent to micro lab for cultures and sensitivities. Approximately 7 mL of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate. After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case. Mouth rinse was then poured into the oral cavity. The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction. Using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space. It was noted on exam that the tooth #1 was fractured off to the gum line with gross decay. Tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5. It was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed. Using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed. The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file. Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed. This site was then irrigated with copious amounts of sterile water. There was still noted to be induration in the buccal mucosa so #15 blade was used anterior to Stensen duct. A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed. A little-to-no pus was received. Using a half-inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 Ethilon suture. Remainder of the flap was left open to drain. Further examination of the floor of mouth was soft. The lateral pharynx was nonindurated or swollen. At this point, the throat pack was removed and OG tube was placed and the stomach contents were evacuated. The procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transferred to the PACU in excellent condition.
## 138 PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:, Subxiphoid pericardiotomy.,ANESTHESIA:, General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:, This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003. She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion. She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. Also, during that time, she had become significantly more short of breath. A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions. She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion. Risks, benefits, and alternative measures were discussed with the patient. Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion. A 4 cm incision was created in the midline above the xiphoid. Dissection was carried down through the fascia and the xiphoid was resected. The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium. An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization. Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc. A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed. The heart was visualized and appeared to be contracting well with no evidence of injury to the heart. The pericardium was then palpated. There was no evidence of studding. A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium. It was sewn into place with #0 silk suture. There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium. It was sewn in the similar way to the other chest tube. Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion. The patient tolerated the procedure well. Chest tubes were placed on 20 cm of water suction. The patient was taken to PACU in stable condition.
## 139 PROCEDURE IN DETAIL:, After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder was performed. It revealed no patholigamentous laxity. We then placed the patient into a beach-chair position, maintaining a neutral alignment of the head, neck, and thorax. The shoulder was then prepped and draped in the usual sterile fashion. We then injected the glenohumeral joint with 60 cc of sterile saline solution. A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Through this incision, a blunt trocar was placed.,We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution. An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint.,We found that the articular surface was in good condition. The biceps was found to be intact. There was a SLAP tear noted just posterior to the biceps. Pictures were taken. No Bankart or Hill-Sachs lesions were noted. The rotator cuff was examined and there were no undersurface tears. Pictures were again taken.,We then made a lateral portal going through the muscle belly of the rotator cuff. A drill hole was made and then knotless suture anchor was placed to repair this. Pictures were taken. We then washed out the joint with copious amounts of sterile saline solution. It was drained. Our 3 incisions were closed using 3-0 nylon suture. A pain pump catheter was introduced into the shoulder joint. Xeroform, 4 x 4s, ABDs, tape, and sling were placed.,The patient was successfully taken out of the beach-chair position, extubated and brought to the recovery room in stable condition. I then went out and spoke with the patient's family, going over the case, postoperative instructions, and followup care.
## 140 PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA: ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS: ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina. The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed. A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed. Two passes were made with the suction curettage. Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus. After the procedure, the vulsellum tenaculum was removed. The cervix was seemed to be hemostatic. The weighted speculum was removed. The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure. After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size. It is now approximately eight to ten-week size. The patient was taken from the operating room in stable condition after she was cleaned. She will be discharged on today. She was given Methergine, Motrin, and doxycycline for her postoperative care. She will follow-up in one week in the office.
## 141 PREOPERATIVE DIAGNOSIS: ,1. Right carpal tunnel syndrome.,2.
## 142 TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma. The patient is having surgery for resection. There was significant cerebellar peduncle compression. The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex. The case took 12 hours. This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:, The patient was brought to the operating room. General anesthesia was induced in the usual fashion. After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area. A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion. The incision was made and cautery was used to expose the suboccipital bone. Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus. The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum. The dura leaves were held back with the 4-0 Nurolon. The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated. Laterally, the arachnoid was very thick. This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified. The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa. Initially two retractors were used, one on the tentorium and one inferiorly. The arachnoid was taken down off the tumor. There were multiple blood vessels on the surface, which were bipolared. The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion. This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized. The redundant capsule was bipolared and cut out to get further access to the center of the tumor. Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex. It was very difficult to identify the 7th nerve complex. The brainstem was identified above the complex. Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain. Attention was then taken to try identify the 7th nerve complex. There were multitude of veins including the lateral pontine vein, which were coming right into this area. The lateral pontine vein was maintained. Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem. A number 1 and number 2 microinstruments were then used to began to develop the plane. This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed. A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve. Cavitron was used to debulk the lesion and then further dissection was carried out. The nerve stimulated beautifully at the brainstem level throughout this. The tumor continued to be mobilized off the lateral pontine vein until it was completely off. The Cavitron was used to debulk the lesion out back laterally towards the area of the porus. The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus. At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus. There was minimal bulk remaining intracranially. All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem. Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor. There was no tumor remaining at this point. I placed some Norian in the porus to seal any air cells, although there were no palpated. An intradural space was then irrigated thoroughly. There was no bleeding. The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time. The dura was then closed with 4-0 Nurolons in interrupted fashion. A muscle plug was used over one area. Duragen was laid and strips over the suture line followed by Hemaseel. Gelfoam was set over this and then a titanium cranioplasty was carried out. The wound was then irrigated thoroughly. O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition.
## 143 PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.
## 144 PREOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,POSTOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,OPERATION:, Repeat irrigation and debridement of above.,ANESTHESIA: , General.,BLOOD LOSS:, Minimal.,FLUID: , Per anesthesia.,DRAINS: , Hemovac times two.,COMPLICATIONS: , None apparent.,SPECIMENS:, To microbiology.,INDICATIONS: , She is a 10-year-old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur. I am bringing her back to the operating room for another exploration of this area and washout. This will be the third procedure for this. At the last time, there was gross purulence that was encountered. Since that time, the patient has defervesced. Her white count is slowly coming down. Her C-reactive protein is slowly coming down.,PROCEDURE IN DETAIL:, After informed consent was obtained, operative site marked, and after preoperative antibiotics were given, the patient was brought back to the operating room and placed supine on the operating table, where Anesthesia induced general anesthesia. The patient's right lower extremity was prepped and draped in normal sterile fashion. Surgical timeout occurred verifying the patient's identification, surgical site, surgical procedure, and administration of antibiotics. The patient's previous incision sites had the sutures removed. We bluntly dissected down through to the IT band. These deep stitches were then removed. We exposed the area of the subperiosteal abscess. The tissue looked much better than at the last surgery. We irrigated this area with three liters of saline containing bacitracin. Next, we made our small medial window to assist with washout of the joint itself. We put another three liters of saline containing bacitracin through the knee joint. Lastly, we did another three liters into the area of the distal femur with three liters of plain saline. We then placed two Hemovac drains, one in the metaphysis and one superficially. We closed the deep fascia with #1 PDS. Subcutaneous layers with 2-0 Monocryl and closed the skin with 2-0 nylon. We placed a sterile dressing. We then turned the case over to Dr. Petty for dressing change and skin graft.,PLAN: ,Our plan will be to pull the drains in 48 hours. We will then continue to watch the patient's fever curve and follow her white count to see how she is responding to the operative and medical therapies.,
## 145 PREOPERATIVE DIAGNOSES:,1. Need for intravenous access.,2. Status post fall.,3. Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1. Need for intravenous access.,2. Status post fall.,3. Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries. The patient went to OR today for an I&D of left lower extremity degloving injury. Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter. All risks and benefits of the procedure were explained and all questions were answered. The patient was prepped and draped in the normal sterile fashion. After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid. Locator needle was used to correctly cannulate the right internal jugular vein. Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach. The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle. A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch. The right subclavian vein was then accessed. A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin. A dilator sheath was placed over the guidewire and subsequently removed. The triple lumen catheter was then placed over the guidewire and advanced to 14 cm. All ports aspirated and flushed. Good blood return was noted and all ports were flushed well. The triple lumen catheter was then secured at 14 cm using #0 silk suture. A sterile dressing was then applied. A stat portable chest x-ray was ordered to check line placement. The patient tolerated the procedure well and there were no complications.
## 146 PREOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,POSTOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,PROCEDURE:,1. Failed percutaneous endoscopic gastrostomy tube placement.,2. Open Stamm gastrotomy tube.,3. Lysis of adhesions.,4. Closure of incidental colotomy.,ANESTHESIA:, General endotracheal anesthesia.,IV FLUIDS:, Crystalloid 1400 ml.,ESTIMATED BLOOD LOSS:, Thirty ml.,DRAINS:, Gastrostomy tube was placed to Foley.,SPECIMENS:, None.,FINDINGS:, Stomach located high in the peritoneal cavity. Multiple adhesions around the stomach to the diaphragm and liver.,HISTORY: ,The patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. He presented initially to the emergency room with throat and bleeding. Following evaluation by ENT and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. The malignancy was not obstructing. Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy.,DESCRIPTION OF PROCEDURE:, The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatively, 1 gram of Ancef was given. The abdomen was prepped and draped in the usual sterile fashion. After anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. With the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. A 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. Both times it was not visualized on the endoscopy. At this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. Again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. At this point, decision was made to convert the procedure to an open Stamm gastrostomy.,OPEN STAMM GASTROSTOMY: ,A short upper midline incision was made and deepened through the subcutaneous tissues. Hemostasis was achieved with electrocautery. The linea alba was identified and incised, and the peritoneal cavity was entered. The abdomen was explored. Adhesions were lysed with electrocautery under direct vision. The stomach was identified, and a location on the anterior wall near the greater curvature was selected. After lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. A pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field. An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. The catheter was then secured to the skin with two #2-0 silk sutures. Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. Prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. This was oversewn with three #4-0 silk Lembert sutures. At the completion of the operation, the fascia was closed with #1 interrupted Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.
## 147 NAME OF PROCEDURE:, Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:, Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:, Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.,ANTICOAGULATION: ,The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.,COMPLICATIONS: , None.,INFORMED CONSENT: , I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,HEMODYNAMIC DATA: , The aortic pressure was in the physiologic range.,ANGIOGRAPHIC DATA: , Left coronary artery: The left main coronary artery showed insignificant disease. The left anterior descending showed fairly extensive calcification. There was 90% stenosis in the proximal to midportion of the vessel. Insignificant disease in the circumflex.,SUCCESSFUL STENTING: , A wire crossed the lesion. We first predilated with a balloon, then advanced, deployed and post dilated the stent. Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30. He is saturating at 96% on 4 L nonrebreather.,GENERAL: The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3. The patient cannot speak and communicates through writing.,HEENT: Very small moles on face. However, pupils equal, round and regular and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is moist.,NECK: Supple. Tracheostomy site is clean without blood or discharge.,HEART: Regular rate and rhythm. No gallop, murmur or rub.,CHEST: Respirations congested. Mild crackles in the left lower quadrant and left lower base.,ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: Cranial nerves II-XII grossly intact. No focal deficit.,GENITALIA: The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,CONCLUSIONS,1. Successful stenting of the left anterior descending. Initially, there was 90% stenosis. After stenting with a drug-eluting stent, there was 0% residual.,2. Insignificant disease in the other coronaries.,PLAN:, The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins. I have discussed this with him, and I have answered his questions.
## 148 PREOPERATIVE DIAGNOSES,1. Intrauterine pregnancy at 39 plus weeks gestation.,2. Gestational hypertension.,3. Thick meconium.,4. Failed vacuum attempted delivery.,POSTOPERATIVE DIAGNOSES,1. Intrauterine pregnancy at 39 plus weeks gestation.,2. Gestational hypertension.,3. Thick meconium.,4. Failed vacuum attempted delivery.,OPERATION PERFORMED: , Spontaneous vaginal delivery.,ANESTHESIA: , Epidural was placed x2.,ESTIMATED BLOOD LOSS:, 500 mL.,COMPLICATIONS: , Thick meconium. Severe variables, Apgars were 2 and 7. Respiratory therapy and ICN nurse at delivery. Baby went to Newborn Nursery.,FINDINGS: , Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.,DESCRIPTION OF OPERATION: , The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks. She was already 3 cm dilated. She had artificial rupture of membranes. Pitocin was started and she actually went to complete dilation. While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations. When she was complete +2, vacuum attempted delivery, three pop-offs were done. The vacuum was then no longer used after the three pop-offs. The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear. Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery. Baby was delivered floppy. Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist. Delivery of intact placenta and three-vessel cord. Third-degree midline tear was repaired with Vicryl without any complications. Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there. Again, mother and baby are both doing well. Mother will go to Postpartum and baby is already in Newborn Nursery.
## 149 PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS: ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003. She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive. She does have a history of sickle cell trait. She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes. She also stated that she has lost her mucous plug. She did have fetal movement, noted no leak of fluid, did have some spotting. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions. She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station. This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:, The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained. After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased. She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position. After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty. The infant was taken to the awaiting pediatrician. Weight was 2870 gm, length was 51 cm. The Apgars were 6 at 1 minute and 9 at 5 minutes. There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45. On examination, there were no noted perineal abrasions or lacerations. On vaginal exam, there were no noted cervical or vaginal sidewall lacerations. Estimated blood loss was less than 250 cc. Mother and infant are in recovery doing well at this time.
## 150 PREPROCEDURE DIAGNOSIS:, Stab wound, left posterolateral chest.,POST PROCEDURE DIAGNOSIS: , Stab wound, left posterolateral chest.,PROCEDURE PERFORMED: , Closure of stab wound.,ANESTHESIA: , 1% lidocaine with epinephrine by local infiltration.,NARRATIVE: ,The wound was irrigated copiously with 500 mL of irrigation and closed in 1 layer with staples after locally anesthetizing with 1% lidocaine with epinephrine. The patient tolerated the procedure well without apparent complications.
## 151 PREOPERATIVE DIAGNOSIS: , Bilateral progressive conductive hearing losses with probable otosclerosis.,POSTOPERATIVE DIAGNOSIS: , Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,OPERATION PERFORMED: , Right argon laser assisted stapedectomy.,DESCRIPTION OF OPERATION: ,The patient was brought to the operating room. Endotracheal intubation carried out by Dr. X. The patient's right ear was carefully prepped and then draped in the usual sterile fashion. Slow infiltration of the external canal accomplished with 1% Xylocaine with epinephrine. The earlobe was also infiltrated with the same solution. A limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5-0 nylon. This could later be removed in bishop. A reinspection of the ear canal was accomplished. A 65 Beaver blade was used to make incision both at 12 o'clock and at 6 o'clock. Jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation. Elevation was carried down to the fibrous annulus. An annulus elevator was used to complete the elevation beneath the annular ligament. The tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain. Palpation of the malleus revealed good mobility of both it and incus, but no movement of the stapes was identified. Palpation with a fine curved needle on the stapes itself revealed no movement. A house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani. The nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well. The self-retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse. The stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured. The fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation. A small bit of additional footplate was removed with a right angle hook to accommodate the 0.6 mm piston. The measuring device was used and a 4.25 mm slim shaft wire Teflon piston chosen. It was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate. The hook was placed over the incus and measurement appeared to be appropriate. A downbiting crimper was then used to complete the attachment of the prosthesis to the incus. Prosthesis is once again checked for location and centering and appeared to be in ideal position. Small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph. A small pledget of fat was also placed on the top of the incudo-prosthesis junction. The mobility appeared excellent. The flap was placed back in its normal anatomic position. The external canal packed with small pledgets of Gelfoam and antibiotic ointment. She was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to Bishop. Sutures will be out in a week and a recheck in Reno in four to five weeks from now.
## 152 PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,ANESTHESIA: , Conscious Sedation.,INFORMED CONSENT: , After adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia (MUA). The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,INDICATION:, This patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,COMMENTS: , This patient understands the essence of the diagnosis and the reasons for the MUA- The associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient. Alternatives to the procedure, including the course of the condition without MUA, were discussed. The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome. The patient has given both verbal and written informed consent for the listed procedure.,PROCEDURE IN DETAIL: , The patient was draped in the appropriate gowning and accompanied to the operative area. Following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure. When the patient and I were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome I desired.,THORACIC SPINE: , With the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine. The first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure. With the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand. The elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure. The procedure was completed at the level of TI-TI2. Cavitation was achieved.,LUMBAR SPINE/SACRO-ILIAC JOINTS:, With the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal. Linear force was used to increase the hip flexion gradually during this maneuver. Simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature. Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver. The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time). This was repeated with the opposite lower extremity. Following this, a Patrick-Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,With the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc. The lower extremity was then tractioned, and straight caudal and internal rotation was accomplished. Using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees. This procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally. These procedures were then repeated on the opposite lower extremity.,By approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance
## 153 PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,PROCEDURE: , Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,ANESTHESIA:, Axillary block plus IV sedation.,ESTIMATED BLOOD LOSS:, Zero.,SPECIMENS,1. Inflammatory synovitis from the volar radial wrist area.,2. Inflammatory synovitis from the dorsal wrist area.,DRAINS:, None.,PROCEDURE DETAIL: , Patient brought to the operating room. After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff. Routine prep and drape was employed. Patient received 1 gm of IV Ancef preoperatively. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet. Tourniquet inflated to 250 mmHg pressure. Hand positioned palm up in a lead hand-holder. A longitudinal zigzag incision over the volar radial wrist mass was made. Skin was sharply incised. Careful blunt dissection was used in the subcutaneous tissue. Antebrachial fascia was bluntly dissected and incised to reveal the radial artery. Radial artery was mobilized preserving its dorsal and palmar branches. Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery. Wrist mass was exposed by blunt dissection. This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule. This was debrided down to the wrist capsule with visualization of the joint through a small capsular window. After complete volar synovectomy the capsular window was closed with 4-0 Mersilene figure-of-eight suture. Subcutaneous tissue was closed with 4-0 PDS and the skin was closed with a running subcuticular 4-0 Prolene. Forearm was pronated and C-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision. An oblique incision overlying the radial styloid centered on the second extensor compartment was made. Skin was sharply incised. Blunt dissection was used in the subcutaneous tissue. Care was taken to identify and protect the superficial radial nerve. Blunt dissection was carried out in the extensor retinaculum. This was incised longitudinally over the second extensor compartment. EPL tendon was identified, mobilized and released to facilitate retraction and prevent injury. The interval between the ECRL and the ECRB was developed down to bone. Dorsal capsulotomy was made and local synovitis was identified. This was debrided and sent as second pathologic specimen. Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a SLAC pattern arthritis. Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer. Dorsally the styloidectomy was beveled smooth and contoured with a rongeur. Final x-rays documenting the styloidectomy were obtained. Local synovitis beneath the joint capsule was debrided. Remnants of the scapholunate interosseous which was completely deteriorated were debrided. The joint capsule was closed anatomically with 4-0 PDS and extensor retinaculum was closed with 4-0 PDS. Subcutaneous tissues closed with 4-0 Vicryl. Skin was closed with running subcuticular 4-0 Prolene. Steri-Strips were applied to wound edge closure; 10 cc of 0.5% plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia. A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home.,DISCHARGE PRESCRIPTIONS:,1. Keflex 500 mg tablets, #20, one PO q.6h. x 5 days.,2. Vicodin, 40 tablets, one to two PO q.4h. p.r.n.,3. Percocet, #20 tablets, one to two PO q.3-4h. p.r.n. severe pain.
## 154 PREOPERATIVE DIAGNOSIS: , Severe scoliosis.,ANESTHESIA: , General. Lines were placed by Anesthesia to include an A line.,PROCEDURES: ,1. Posterior spinal fusion from T2-L2.,2. Posterior spinal instrumentation from T2-L2.,3. A posterior osteotomy through T7-T8 and T8-T9. Posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,IMPLANT: , Sofamor Danek (Medtronic) Legacy 5.5 Titanium system.,MONITORING: , SSEPs, and the EPs were available.,INDICATIONS: , The patient is a 12-year-old female, who has had a very dysmorphic scoliosis. She had undergone a workup with an MRI, which showed no evidence of cord abnormalities. Therefore, the risks, benefits, and alternatives were discussed with Surgery with the mother, to include infections, bleeding, nerve injuries, vascular injuries, spinal cord injury with catastrophic loss of motor function and bowel and bladder control. I also discussed ___________ and need for revision surgery. The mom understood all this and wished to proceed.,PROCEDURE: , The patient was taken to the operating room and underwent general anesthetic. She then had lines placed, and was then placed in a prone position. Monitoring was then set up, and it was then noted that we could not obtain motor-evoked potentials. The SSEPs were clear and were compatible with the preoperative, but no preoperative motors had been done, and there was a concern that possibly this could be from the result of the positioning. It was then determined at that time, that we would go ahead and proceed to wake her up, and make sure she could move her feet. She was then lightened under anesthesia, and she could indeed dorsiflex and plantarflex her feet, so therefore, it was determined to go ahead and proceed with only monitoring with the SSEPs.,The patient after being prepped and draped sterilely, a midline incision was made, and dissection was carried down. The dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes. This occurred from T2-L2. Fluoroscopy was brought in to verify positions and levels. Once this was done, and all bleeding was controlled, retractors were then placed. Attention was then turned towards placing screws first on the left side. Lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance. The area was opened with a high speed burr, and then the track was defined with a blunt probe, and a ball-tipped feeler was then utilized to verify all walls were intact. They were then tapped, and then screws were then placed. This technique was used at L1 and L2, both the right and left. At T12, a direct straight-ahead technique was utilized, where the facet was removed, and then the position was chosen under the fluoroscopy, and then it was spurred, the track was defined and then probed and tapped, and it was felt to be in good position. Two screws, in the right and left were placed at T12 as well, reduction screws on the left. The same technique was used for T11, where right and left screws were placed as well as T10 on the left. At T9, a screw was placed on the left, and this was a reduction screw. On the left at T8, a screw could not be placed due to the dysmorphic nature of the pedicle. It was not felt to be intact; therefore, a screw was left out of this. On the right, a thoracic screw was placed as well as at 7 and 6. This was the dysmorphic portion of this. Screws were attempted to be placed up, they could not be placed, so attention was then turned towards placing pedicle hooks. Pedicle hooks were done by first making a box out of the pedicle, removing the complete pedicle, feeling the undersurface of the pedicle with a probe, and then seating the hook. Upgoing pedicle hooks were placed at T3, T4, and T5. A downgoing laminar hook was placed at the T7 level. Screws had been placed at T6 and T7 on the right. An upgoing pedicle hook was also placed at T3 on the right, and then, downgoing laminar hooks were placed at T2. This was done by first using a transverse process, lamina finders to go around the transverse process and then ___________ laminar hooks. Once all hooks were in place, spinal osteotomies were performed at T7-T8 and T8-T9. This was the level of the kyphosis, to bring her back out of her kyphoscoliosis. First the ligamentum flavum was resected using a large Kerrisons. Next, the laminotomy was performed, and then a Kerrison was used to remove the ligamentum flavum at the level of the facet. Once this was accomplished, a laminotomy was performed by removing more of the lamina, and to create a small wedge that could be closed down later to correct the kyphosis. This was then brought out with resection of bone out to the foramen, doing a foraminotomy to free up the foramen on both sides. This was done also between the T8-T9. Once this was completed, Gelfoam was then placed. Next, we observed, and measured and contoured. The rods were then seated on the left, and then a derotation maneuver was performed. Hooks had come loose, so the rod was removed on the left. The hooks were then replaced, and the rod was reseated. Again, it was derotated to give excellent correction. Hooks were then well seated underneath, and therefore, they were then locked. A second rod was then chosen on the right, and was measured, contoured, and then seated. Next, once this was done, the rods were locked in the midsubstance, and then the downgoing pedicle hook, which had been placed at T7 was then helped to compress T8 as was the pedicle screw, and then this compressed the osteotomy sites quite nicely. Next, distraction was then utilized to further correct at the spine, and to correct on the left, the left concave curve, which gave excellent correction. On the right, compression was used to bring it down, and then, in the lower lumbar areas, distraction and compression were used to level out L2. Once this was done, all screws were tightened. Fluoroscopy was then brought in to verify L1 was level, and the first ribs were also level, and it gave a nice balanced spine. Everything was copiously irrigated, ___________. Next, a wake-up test was performed, and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet. The patient was then again sedated and brought back under general anesthesia. Next, a high-speed burr was used for decortication. After final tightening had been accomplished, and then allograft bone and autograft bone were mixed together with 10 mL of iliac crest aspirate and were placed into the wound. The open canal areas had been protected with Gelfoam. Once this was accomplished, the deep fascia was closed with multiple figure-of-eight #1's, oversewn with a running #1, _________ were then placed in the subcutaneous spaces which were then closed with 3-0 Vicryl, and then the skin was closed with 3-0 Monocryl and Dermabond. Sterile dressing was applied. Drains had been placed in the subcutaneous layer x2. The patient during the case had no changes in the SSEPs, had a normal wake-up test, and had received Ancef and clindamycin during the case. She was taken from the operating room in good condition.
## 155 PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES: ,1. Anterior spine fusion from T11-L3.,2. Posterior spine fusion from T3-L5.,3. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis. This was found to be moderately corrected. Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis. He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression. Risks and benefits were discussed at length with the family over many visits. They wished to proceed.,PROCEDURE:, The patient was brought to the operating room and placed on the operating table in the supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. Appropriate lines were then placed. He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up. An oblique incision was then made over the flank overlying the 10th rib. Underlying soft tissues were incised down at the skin incision. The rib was then identified and subperiosteal dissection was performed. The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally. This allowed for entry into the pleural space. The lung was then packed superiorly with wet lap. The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies. This required cauterization of the segmental vessels. Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed. These were performed from T11-L3. This was over 5 levels. Disks and endplates were then removed. Once this was performed, morcellized rib autograft was placed into the spaces. The table had been previously bent to allow for easier access of the spine. This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity. The ribs were held together with #1 Vicryl sutures. Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well. Skin was closed as needed with running #4-0 Monocryl. This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position. The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5. The underlying soft tissues were incised down at the skin incision. Electrocautery was then used to maintain hemostasis. The spinous processes were then identified and the overlying apophyses were split. This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes. Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine. These were placed at L4 and L5. The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum. This was done using a rongeur as well as a Kerrison rongeur. Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed. These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned. This was secured initially at the screws distally on both the left and right side. The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine. This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin. This was done using pulsed lavage.,The wound was then closed in layers. The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed. The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape. The patient was awakened from anesthesia and taken to the intensive care unit in stable condition. All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.
## 156 PREOPERATIVE DIAGNOSIS:, Right spermatocele.,POSTOPERATIVE DIAGNOSIS: ,Right spermatocele.,OPERATIONS PERFORMED:,1. Right spermatocelectomy.,2. Right orchidopexy.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: ,The patient is a 77-year-old male who comes to the office with a large right spermatocele. The patient says it does bother him on and off, has occasional pain and discomfort with it, has difficulty with putting clothes on etc. and wanted to remove. Options such as watchful waiting, removal of the spermatocele or needle drainage were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, risk of infection, scrotal pain, and testicular pain were discussed. The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down. The patient was told about the risk of recurrence of spermatocele. The patient understood all the risks, benefits, and options and wanted to proceed with removal.,DETAILS OF THE PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient's scrotal area was shaved, prepped, and draped in the usual sterile fashion. A midline scrotal incision was made measuring about 2 cm in size. The incision was carried through the dartos through the scrotal sac and the spermatocele was identified. All the layers of the spermatocele were removed. Clear layer was visualized, was taken all the way up to the base, the base was tied. Entire spermatocele sac was removed. After removing the entire spermatocele sac, hemostasis was obtained. The testicle was not in normal orientation. The testis and epididymis was removed, which is a small appendage on the superior aspect of the testicle. The testicle was placed in a normal orientation. Careful attention was drawn not to twist the cord. Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4-0 Vicryl and was tied at 3 different locations. Absorbable sutures were used, so that the patient does not feel the sutures in the postoperative period. The dartos was closed using 2-0 Vicryl in running locking fashion. There was excellent hemostasis. The skin was closed using 4-0 Monocryl. Dermabond was applied. The patient tolerated the procedure well. The patient was brought to the recovery room in stable condition.
## 157 HISTORY: ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation. Information is obtained in discussion with the mother and the grandmother in review of previous medical records. This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning. Then, the patient was noted to vomit after feeds. The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range. The patient underwent a barium enema, which was read by the radiologist as negative. The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital. Birth weight was 6 pounds 4 ounces. There was maternal hypertension. Mother denies group B strep or herpes. Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: ,Here with mother and grandmother, lives at home. There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS: ,The patient is fed Enfamil, bottle-fed. Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL: On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle. Pupils are equal, round, and reactive to light. Grossly conjugate. Bilateral red reflex appreciated bilaterally. Clear TMs, nose, and oropharynx. There is a kind of abundant thrush and white patches on the tongue.,NECK: Supple, full, painless, and nontender range of motion.,CHEST: Clear to auscultation, equal, and stable.,HEART: Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN: Soft and nontender. No hepatosplenomegaly or masses.,GENITALIA: Female genitalia is present on a visual examination.,SKIN: No significant bruising, lesions, or rash.,EXTREMITIES: Moves all extremities, and nontender. No deformity.,NEUROLOGICALLY: Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome. The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos. Serum electrolytes not normal. Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4. AST and ALT were elevated as well at 412 and 180 respectively. A cath urinalysis showing no signs of infection. Spinal fluid evaluation, please see procedure note below. White count 0, red count 2060. Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain. The fluid was obtained, the needle was removed, and sterile bandage was placed. The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well. An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12. A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast. Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids. Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued. The patient was admitted to the Hospitalist Service for continued IV fluids. The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula. She has not had any vomiting, is burping. The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration. Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.
## 158 DIAGNOSIS:, Stasis ulcers of the lower extremities,OPERATION:, Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:, This 84-year old female presented recently with large ulcers of the lower extremities. These were representing on the order of 50% or more of the circumference of her lower leg. They were in a distribution to be consistent with stasis ulcers. They were granulating nicely and she was scheduled for surgery.,FINDINGS:, Large ulcers of lower extremities with size as described above. These are irregular in shape and posterior and laterally on the lower legs. There was no evidence of infection. The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes. The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin. The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed. Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch. This was meshed 1:1.5 and then stapled into position on the wounds. The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels. The donor site was dressed with Op-Site. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
## 159 PREOPERATIVE DX: , Stress urinary incontinence.,POSTOPERATIVE DX: , Stress urinary incontinence.,OPERATIVE PROCEDURE: , SPARC suburethral sling.,ANESTHESIA: , General.,FINDINGS & INDICATIONS: , Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence. Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations. The ureteral orifices were normal bilaterally.,DESCRIPTION OF OPERATIVE PROCEDURE:, This patient was brought to the operating room, a general anesthetic was administered. She was placed in dorsal lithotomy position. Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution. She was draped in usual sterile fashion. A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder. Two Allis clamps were placed over the mid urethra. This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution. Two areas suprapubically on either side of midline were injected with the same anesthetic solution. The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra. Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus. The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally. The Foley catheter was removed. A cystoscopy was performed using a 70-degree cystoscope. There was noted to be no violation of the bladder. The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions. The mesh was snugged up against a Mayo scissor held under the mid urethra. The overlying plastic sheaths were removed. The mesh was cut below the surface of the skin. The skin was closed with 4-0 Plain suture. The vaginal vault was closed with a running 2-0 Vicryl stitch. The blood loss was minimal. The patient was awoken and she was brought to recovery in stable condition.
## 160 PREOPERATIVE DIAGNOSIS:, Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was brought into the operating room, placed on the table in supine position. General endotracheal anesthesia was obtained in the usual fashion. The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen. The neck was prepped as well. After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl. A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle. After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible. The condyle was skeletonized so that it could be easily seen. The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared. The neck contents to the hyoid were dissected out. The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen. The neck contents were removed as a separate specimen. The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis. A large posterior facial vein was identified and likewise clipped for later use. I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb. It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube. The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made. I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion. Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy. For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap. A skin paddle was drawn out next to the umbilicus about 4 x 4 cm. The skin paddle was incised with the Bovie and down to the anterior rectus sheath. Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle. The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin. The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl. The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction. The vascular pedicle could be seen entering the muscle in usual fashion. The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel. The wound was then packed with saline impregnated sponges. The rectus muscle with attached skin paddle was then transferred into the neck. The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique. Ischemia time was less than 10 minutes. Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well. There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case. The wound was irrigated with copious amounts of saline. The eustachian tube was obstructed with bone wax. The muscle was then laid into position with the skin paddle underneath the conchal bowl. I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place. The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull. The subcutaneous tissues were closed with interrupted 3-0 Vicryl. The skin was closed with skin staples. There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself. The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors. The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples. The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened. The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.
## 161 PROCEDURE: ,The site was cleaned with antiseptic. A local anesthetic (2% lidocaine) was given at each site. A 3 mm punch biopsy was performed in the left calf and left thigh, above the knee. The site was then checked for bleeding. Once hemostasis was achieved, a local antibiotic was placed and the site was bandaged.,The patient was not on any anticoagulant medications. There were also no other medications which would affect the ability to conduct the skin biopsy. The patient was further instructed to keep the site completely dry for the next 24 hours, after which a new Band-Aid and antibiotic ointment should be applied to the area. They were further instructed to avoid getting the site dirty or infected. The patient completed the procedure without any complications and was discharged home.,The biopsy will be sent for analysis.,The patient will follow up with Dr. X within the next two weeks to review her results.
## 162 PREOPERATIVE DIAGNOSES:,1. Nasopharyngeal mass.,2. Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1. Nasopharyngeal tube mass.,2. Right upper lid skin lesion.,PROCEDURES PERFORMED:,1. Functional endoscopic sinus surgery.,2. Excision of nasopharyngeal mass via endoscopic technique.,3. Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease. The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan. The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months. It appears to be growing in size and is irregularly bordered. After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position. After this, the patient was turned to 90 degrees by the Department of Anesthesia. The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total. After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total. The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade. After this, the skin lesion was then grasped with a ________ in the superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors. After this, the ________ was then hemostatically controlled with monopolar cauterization. The patient's skin was then reapproximated with a running #6-0 Prolene suture. A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment. Attention then was drawn to the nasopharynx. The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx. The patient had a severely deviated nasal septum more so to the right than the left. There appeared to be a spur on the left inferior aspect and also on the right posterior aspect. The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking. It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total. After this, the lesion was then removed on the right side with the XPS blade. The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely. This area was taken down with the XPS blade. Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter. After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side. The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx. Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius. After this, the patient was then hemostatically controlled with suctioned Bovie cauterization. A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment. The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia. The patient was extubated in the operating room and was transferred to the recovery room in stable condition. The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week. The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30.
## 163 PREOPERATIVE DIAGNOSES:,1. Depressed anterior table frontal sinus fracture on the right side.,2. Right nasoorbital ethmoid fracture.,3. Right orbital blowout fracture with entrapped periorbita.,4. Nasal septal and nasal pyramid fracture with nasal airway obstruction.,POSTOPERATIVE DIAGNOSES:,1. Depressed anterior table frontal sinus fracture on the right side.,2. Right nasoorbital ethmoid fracture.,3. Right orbital blowout fracture with entrapped periorbita.,4. Nasal septal and nasal pyramid fracture with nasal airway obstruction.,OPERATION:,1. Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus.,2. Transconjunctival exploration of right orbital floor with release of entrapped periorbita.,3. Open reduction of nasal septum and nasal pyramid fracture with osteotomy.,ANESTHESIA:, General endotracheal anesthesia.,PROCEDURE: , The patient was placed in the supine position. Under affects of general endotracheal anesthesia, head and neck were prepped and draped with pHisoHex solution and draped in the appropriate sterile fashion. A gull-wing incision was drawn over the forehead scalp. Hair was removed along the suture line and incision was made to skin and subcutaneous tissue of the scalp down to, but not including the pericranium. An inferiorly based forehead flap was then elevated to the superior orbital rim. The depression of the anterior table of the frontal sinus was noted. An incision was made more posterior creating an inferiorly based pericranial flap. The supraorbital nerve was axing from the supraorbital foramen and the supraorbital foramen was converted to a groove in order to allow further inferior displacement and positioning of the forehead flap. These allowed exposure of the medial orbital wall on the right side. The displaced fractures of the right medial orbital wall were repositioned through coronal approach. ,Further reduction of the nose intranasally also allowed the ethmoid fracture to be aligned more appropriately in the medial wall. The anterior table fracture was satisfactorily reduced. Multiple 1.3-mm screws and plate fixation were utilized to recontour the anterior forehead. A mucocele was removed from the frontal sinus and there was no significant destruction of the posterior wall. A sinus seeker was utilized and passed into the nasofrontal duct without difficulty. It was felt that the frontal sinus obliteration would not be necessary.,At this point, the pericranial flap was folded in a fan-folded fashion on top of the plate and screw and hardware and fixed in position with the sutures to remain better contour of the forehead. At this point, the nose was significantly shifted to the left and an open reduction of the nasal fracture was performed by osteotomies, which were made medially, laterally, and percutaneous transverse osteotomy of the nasal bone on the right side. There is significant depression of the nasal bone on the left side. A medial osteotomy was performed on the left side mobilizing nasal pyramid satisfactorily. There is a high septal deviation, which would not allow complete correction of the deviation. It was felt that this would best be left for a later date. Open reduction rhinoplasty could be performed with spread of cartilage grafting in order to straighten the septum high dorsally. Local infiltration anesthesia 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the conjunctival fornix of the right lower eyelid as well as the inferior orbital rim. An incision was made in the palpebral conjunctiva and capsular palpebral fascia beneath the tarsal plate preseptal approach to the inferior orbital rim was performed in this fashion. Dissection proceeded down to the inferior orbital rim and subperiosteal dissection was performed over the orbital floor. Hemostasis was achieved with electrocautery. There was entrapped periorbita, which was released to the fractures, which were repositioned, but not fixed in position. The forced ductions were performed, which demonstrated release of the periorbit satisfactorily. The conjunctival incision was closed with an interrupted simple 6-0 plain gut suture. The nasal pyramid was satisfactorily mobilized as well as the nasal septum and brought back to midline position with the help of a Boies elevator for the septum. The coronal incision was closed with interrupted 3-0 PDS suture for the galea and deep subcutaneous tissue and the skin closed with interrupted surgical staples. Nose was dressed with Steri-Strips. Mastisol Orthoplast splint was prepared after the Doyle splints were placed in the nose and secured with 3-0 Prolene suture and the nose packed with two Kennedy Merocel sponges. A supportive mildly compressive dressing with fluffs, Kerlix, and 4-inch Ace were applied. The patient tolerated the procedure well and was returned to recovery room in satisfactory condition.
## 164 PREOPERATIVE DIAGNOSES:,1. Left spermatocele.,2. Family planning.,POSTOPERATIVE DIAGNOSES:,1. Left spermatocele.,2. Family planning.,PROCEDURE PERFORMED:,1. Left spermatocelectomy/epididymectomy.,2. Bilateral partial vasectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Minimal.,SPECIMEN: , Left-sided spermatocele, epididymis, and bilateral partial vasectomy.,DISPOSITION: ,To PACU in stable condition.,INDICATIONS AND FINDINGS: , This is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort. The patient also has family status complete and desired infertility. The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,FINDINGS: , At this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was moved to the operating room. A general anesthesia was induced by the Department of Anesthesia.,The patient was prepped and draped in the normal sterile fashion for a scrotal approach. A #15 blade was used to make a transverse incision on the left hemiscrotum. Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field. The left testicle was examined. A large spermatocele was noted. Metzenbaum scissors were used to dissect the tissue around the left spermatocele. Once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis. Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery. Electrocautery was used to confirm excellent hemostasis. Attention was then turned to the more proximal aspect of the cord. The vas deferens was palpated and dissected free with Metzenbaum scissors. Hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends. Testicle was placed back in the scrotum in appropriate anatomic position. The dartos tissue was closed with running #3-0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic. Attention was then turned to the right side. The vas was palpated in the scrotum. A small skin incision was made with a #15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field. A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat. Two ends were hemostated with hemostats and divided with Metzenbaum scissors. Lumen was coagulated with electrocautery. Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum. A #4-0 chromic suture was used in simple fashion to reapproximate the skin incision. Scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied. The patient was sent to Recovery in stable condition. He was given prescriptions for doxycycline 100 mg b.i.d., for five days and Vicodin ES 1 p.o. q.4h. p.r.n., pain, #30 for pain. The patient is to followup with Dr. X in seven days.
## 165 PREOPERATIVE DIAGNOSIS:, Blocked ventriculoperitoneal shunt.,POSTOPERATIVE DIAGNOSIS:, Blocked ventriculoperitoneal shunt.,PROCEDURE: , Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,ANESTHESIA: , General.,HISTORY: , The patient is nonverbal. He is almost 3 years old. He presented with 2 months of irritability, vomiting, and increasing seizures. CT scan was not conclusive, but shuntogram shows no flow through the shunt.,DESCRIPTION OF PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with his head turned to the left. Scalp was clipped. He was prepped on the head, neck, chest and abdomen with ChloraPrep. Incisions were infiltrated with 0.5% Xylocaine with epinephrine 1:200,000. He received oxacillin.,He was then reprepped and draped in a sterile manner.,The frontal incision was reopened and extended along the valve. Subcutaneous sharp dissection with Bovie cautery was done to expose the shunt parts. I separated the ventricular catheter from the valve, and this was a medium pressure small contour Medtronic valve. There was some flow from the ventricular catheter, but not as much as I would expect. I removed the right-angled clip with a curette and then pulled out the ventricular catheter, and there was gushing of CSF under high pressure. So, I do believe that the catheter was obstructed, although inspection of the old catheter holes did not show any specific obstructions. A new Codman BACTISEAL catheter was placed through the same hole. I replaced it several times because I wanted to be sure it was in the cavity. It entered easily and there was still just intermittent flow of CSF. The catheter irrigated very well and seemed to be patent.,I tested the distal system with an irrigation filled feeding tube, and there was excellent flow through the distal valve and catheter. So I did not think it was necessary to replace those at this time. The new catheter was trimmed to a total length of 8 cm and attached to the proximal end of the valve. The valve connection was secured to the pericranium with a #2-0 Ethibond suture. The wound was irrigated with bacitracin irrigation. The shunt pumped and refilled well. The wound was then closed with #4-0 Vicryl interrupted galeal suture and Steri-Strips on the skin. It was uncertain whether this will correct the problem or not, but we will continue to evaluate. If his abdominal pressure is too high, then he may need a different valve. This will be determined over time, but at this time, the shunt seemed to empty and refill easily. The patient tolerated the procedure well. No complications. Sponge and needle counts were correct. Blood loss was minimal. None replaced.
## 166 PREOPERATIVE DIAGNOSIS:, Right renal stone.,POSTOPERATIVE DIAGNOSIS: ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:, Minimal. The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presented with right renal stone and right UPJ stone. The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney. The plan was for shockwave lithotripsy. The patient had duplicated system on the right side. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed. Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed. The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily. Consent was obtained.,DETAILS OF THE OPERATION: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in the supine position. Using Dornier lithotriptor total of 2500 shocks were applied. Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up. The shocks were started at 60 per minute and slowly increased up to 90 per minute. The patient's heart rate and blood pressure were stable throughout the entire procedure.,After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion and cystoscopy was done. Using graspers, the stent was grasped x2 and pulled out, both stents were removed. The patient tolerated the procedure well. The patient was brought to recovery in stable condition. The plan was for the patient to follow up with us and plan for KUB in about two to three months.
## 167 PREOPERATIVE DIAGNOSIS: , Shunt malfunction.,POSTOPERATIVE DIAGNOSIS: , Partial proximal obstruction, patent distal system.,TITLE OF OPERATION: , Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,SPECIMENS: ,None.,COMPLICATIONS:, None.,ANESTHESIA:, General.,SKIN PREPARATION: ,Chloraprep.,INDICATIONS FOR OPERATION: , Headaches, irritability, slight increase in ventricle size. Preoperatively patient improved with Diamox.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the supine position with the head rotated towards the left. The right frontal area and right retroauricular area was shaved and then the head, neck, chest and abdomen were prepped and draped out in the routine manner. The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter, right over the sleeve on top of it and when that was entered, the CSF poured out around the ventricular catheter. The ventricular catheter was then disconnected from the reservoir and endoscopically explored. We saw it was blocked up proximally. The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter, I was able to free up the ventricular catheter, and endoscopically inserted a new Bactiseal ventricular catheter. The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle. It irrigated out well. There was minimal amount of bleeding, but not significant. The distal catheter system was tested. There was good distal run off. Therefore, a linear skin incision was made in the retroauricular area. Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1-5 shunt assist was brought through the subgaleal tissue, connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve. All connections were secured with 2-0 Ethibond sutures. Careful attention was made to make sure that the ProGAV was in the right orientation. The wounds were irrigated out with Bacitracin, closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips. The patient tolerated the procedure well. He was awakened, extubated and taken to recovery room in satisfactory condition.
## 168 PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:, Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:, None. The patient was taken to Postanesthesia Care Unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder. X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid. She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head. All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention. The patient still wanted to proceed forward with surgical intervention. The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The patient was moved to a beach chair position. All extremities were well padded. Her head was well padded to the table. Her right upper extremity was draped in sterile fashion. A saber incision was made from the coracoid down to the axilla. Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case. Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made. Subscapularis tendon was released. The humeral head was brought in to; there were large osteophytes that were removed with an osteotome. The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region. A sizer was placed. It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin. This was placed, after which a reamer was placed along the humeral head and reamed to a size 5. All extra osteophytes were excised. The supraspinatus and infraspinatus tendons were intact. Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation. The arm had excellent range of motion. There are no signs of gross dislocation. Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head. Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position. After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction. There was no gross sign of dislocation. Wound site once again it was copiously irrigated with saline antibiotics. The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon. After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl. The skin was closed with staples. A sterile dressing was placed. The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.
## 169 PREOPERATIVE DIAGNOSIS: , Shunt malfunction. The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:, Shunt malfunction. The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:, Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:, None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:, After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner. The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn. The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped. Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around. We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction. A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle. It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures. The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips. The patient was awakened and extubated having tolerated the procedure well without complications. It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.
## 170 TITLE OF OPERATION:, Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:, Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:, Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:, After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding. The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping. Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles. The patient also had a right subtemporal depression, which was full preoperatively. The entire old apparatus was dissected out. We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted. They were both inspected. No definite debris were seen. After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter. On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location. The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture. The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir. All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips. The patient tolerated the procedure well without complications. CSF was not sent off.
## 171 PROCEDURE: , Sigmoidoscopy.,INDICATIONS:, Performed for evaluation of anemia, gastrointestinal Bleeding.,MEDICATIONS: , Fentanyl (Sublazine) 0.1 mg IV Versed (midazolam) 1 mg IV,BIOPSIES: , No BRUSHINGS:,PROCEDURE:, A history and physical examination were performed. The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this. Opportunity for questions was provided and informed consent obtained. After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm. Careful inspection was made as the sigmoidoscope was withdrawn. The quality of the prep was good. The procedure was stopped due to patient discomfort. The patient otherwise tolerated the procedure well. There were no complications.,FINDINGS: , Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries. Retroflexed examination of the rectum revealed small hemorrhoids. External hemorrhoids were found. Other than the findings noted above, the visualized colonic segments were normal.,IMPRESSION: , Internal hemorrhoids External hemorrhoids Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries. Unsuccessful Sigmoidoscopy. Otherwise Normal Sigmoidoscopy to 25 cm. External hemorrhoids were found.
## 172 OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.,Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea. The 2nd tracheal ring was identified. Next, a #11-blade scalpel was used to make a trap door in the trachea. The endotracheal tube was backed out. A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit. We then secured it in place using 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well.
## 173 PREOPERATIVE DIAGNOSIS: , Sebaceous cyst, right lateral eyebrow.,POSTOPERATIVE DIAGNOSIS:, Sebaceous cyst, right lateral eyebrow.,PROCEDURE PERFORMED: , Excision of sebaceous cyst, right lateral eyebrow.,ASSISTANT: , None.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable. Transferred to the recovery room.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old with a history of sebaceous cyst. The patient is undergoing PE tubes by Dr. X and I was asked to remove the cyst on the right lateral eyebrow. I saw the patient in my clinic. I explained to the mother in Spanish the risk and benefits. Risk included but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgery. We will proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was taken into the operating room, placed in the supine position. General anesthetic was administered. A prophylactic dose of antibiotic was given. The patient was prepped and draped in a usual manner. The procedure began by infiltrating lidocaine with epinephrine around the cyst area. Then, I proceeded with the help of a 15C blade to make an incision and remove a small wedge of tissue that includes a comedo point. The incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst. The cyst was detached of the surrounding structure with the help of blunt dissection. Hemostasis was achieved with electrocautery. The wound was closed with 5-0 Vicryl deep dermal interrupted stitches and Dermabond. The patient tolerated the procedure well without complications and transferred to recovery room in stable condition. I was present and participated in all aspects of the procedure. Sponge, needle, and instrument counts were completed at the end of the procedure.
## 174 PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1. Open septorhinoplasty with placement of bilateral spreader grafts.,2. Placement of a radiated rib tip graft.,3. Placement of a morcellized autogenous cartilage dorsal onlay graft.,4. Placement of endogen, radiated collagen dorsal onlay graft.,5. Placement of autogenous cartilage columellar strut graft.,6. Bilateral lateral osteotomies.,7. Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8. Fracture of right upper lateral cartilage.,ANESTHESIA: ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,100 mL.,URINE OUTPUT:, Not recorded.,SPECIMENS:, None.,DRAINS: , None.,FINDINGS: ,1. The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2. The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3. The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity. The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity. He was found to have a C-shaped deformity to the left as well as some tip ptosis. The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table. The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty. The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees. Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally. The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally. Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision. This incision was made using a #15 blade. A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura. However, there was a dissection injury to the left medial crura. Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage. Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion. Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions. There was also an obvious fracture of the right upper lateral cartilage. There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump. The skin was contributing to the patient's cosmetic deformity. In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage. This mucocele was attempted to be dissected free, most of which was removed via dissection. We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome. The dorsal hump was taken down and passed off the table. Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage. This was passed off to use later for possible onlay grafts. There was now a marked open roof deformity of the cartilage and bony sprue. A septoplasty was then performed throughout and a Kelly incision on the right side. Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side. A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut. This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities. The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally. Once these were placed, we then proceeded to work on the bony open roof. Lateral osteotomies were made with 2-mm osteotomes bilaterally. The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum. We then proceeded to the tip. A cartilaginous strut was then fashioned from the cartilaginous septum. It was approximately 15 mm long. This was placed, and a pocket was just formed between the medial crura. This pocket was taken down to the nasal spine, and then, the strut graft was placed. The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition. The intradermal sutures were then placed to help to align the nasal tip. The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing. Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot. The patient had good tip support after this maneuver. We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome. This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen. The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft. Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages. Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts. This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness. There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point. The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion. The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture. Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture. The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct. A Denver external splint was then applied. The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition.
## 175 PREOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,POSTOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,PROCEDURE: , Left scrotal exploration with detorsion. Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.,ANESTHETIC:, A 0.25% Marcaine local wound insufflation per surgeon, 15 mL of Toradol.,FINDINGS:, Congestion in the left testis and cord with a bell-clapper deformity on the right small appendix testes bilaterally. No testis necrosis.,ESTIMATED BLOOD LOSS:, 5 mL.,FLUIDS RECEIVED: , 300 mL of crystalloid.,TUBES AND DRAINS:, None.,SPECIMENS: , No tissues sent to pathology.,COUNTS:, Sponges and needle counts were correct x2.,INDICATIONS OF OPERATION: , The patient is a 4-year-old boy with abrupt onset of left testicular pain. He has had a history of similar onset. Apparently, he had no full on one ultrasound and full on a second ultrasound, but because of possible torsion, detorsion, or incomplete detorsion, I recommended an exploration.,DESCRIPTION OF OPERATION:, The patient was taken to the operating room, where surgical consent, operative site, and patient identification was verified. Once he was anesthetized, he was placed in supine position and sterilely prepped and draped. Superior scrotal incisions were then made with 15-blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery. Electrocautery was used for hemostasis. The subdartos pouch was created with curved tenotomy scissors. The tunica vaginalis was then delivered, incised, and testis was delivered. The testis itself with a bell-clapper deformity. There was no actual torsion at the present time, there was some modest congestion and, however, the vasculature was markedly congested down the cord. The penis fascia was cauterized and subdartos pouch was created. The upper aspect of fascia was then closed with pursestring suture of 4-0 chromic. The testis was then placed into the scrotum in a proper orientation. No tacking sutures within the testis itself were used. The tunica vaginalis; however, was wrapped perfectly behind the back of the testis. A similar procedure was performed on the right side. Again, an appendix testis was cauterized. No torsion was seen. He also had a bell-clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with #4-0 chromic suture. The local anesthetic was then used for both as cord block, as well as a local wound insufflation bilaterally with 0.25% Marcaine. The scrotal wall was then closed with subcuticular closure of #4-0 chromic. Dermabond tissue adhesive was then used. The patient tolerated the procedure well. He was given IV Toradol and was taken to the recovery room in stable condition.
## 176 PROCEDURE IN DETAIL:, After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. The 4 rectus muscles were looped and isolated using 2-0 silk suture. The retinal periphery was then inspected via indirect ophthalmoscopy.,
## 177 PREOPERATIVE DIAGNOSIS AND INDICATIONS:, Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:, The patient presented with an acute non-ST-elevation MI. Despite medical therapy, she continued to have intermittent angina. Angiography demonstrated the severe LAD as the culprit lesion. This was treated as noted above with angioplasty alone as the stent could not be safely advanced. She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above. She will be continued on her medical therapy. At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:, After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position. The area of the right femoral artery was prepped and draped in a sterile fashion. Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance. With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system. The catheter was removed. The sheath flushed. The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery. The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI. The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower. We repeated the level and it was slightly higher. We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV. Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal. An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated. Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent. The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium. The balloon was inflated and removed, repeat angiography performed. We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification. The stent was removed. Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful. It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed. Repeat angiography demonstrated no evidence of dissection. One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal. I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed. The guidewires and guide cath were removed. The sheath flushed and sutured into position. The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:, Aorta 185/54.,Left ventriculography was not performed. I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels. The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal. The LAD has significant calcification proximally. There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent. This resulted in a 30% residual, mostly eccentric calcified plaque. Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal. This was not ballooned. Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal. These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal. As noted above, this area was not stented because I could not safely advance the stent. Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches. The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal. The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch. The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch. The remainder of the right coronary and its branches were without significant disease.
## 178 PREOPERATIVE DIAGNOSES:,1. Nasal septal deviation.,2. Bilateral internal nasal valve collapse.,3. Bilateral external nasal valve collapse.,POSTOPERATIVE DIAGNOSES:,1. Nasal septal deviation.,2. Bilateral internal nasal valve collapse.,3. Bilateral external nasal valve collapse.,PROCEDURES:,1. Revision septoplasty.,2. Repair of internal nasal valve collapse using auricular cartilage.,3. Repair of bilateral external nasal valve collapse using auricular cartilage.,4. Harvest of right auricular cartilage.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Approximately 20 mL.,IV FLUIDS: , Include a liter of crystalloid fluid.,URINE OUTPUT: , None.,FINDINGS: , Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor. There is also evidence of bilateral internal as well as external nasal valve collapse.,INDICATIONS: ,The patient is a pleasant 49-year-old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s. He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine. Therefore, for repair of the above-mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum, the risks and benefits of the procedure were discussed with him included but not limited to bleeding, infection, septal perforation, need for further surgeries, external deformity, and he desired to proceed with surgery.,DESCRIPTION OF THE PROCEDURE IN DETAIL: ,The patient was taken to the operating room and laid supine upon the OR table. After the induction of general endotracheal anesthesia, the nose was decongested using Afrin-soaked pledgets followed by the injection of % lidocaine with 1:100,000 epinephrine in the submucoperichondrial planes bilaterally. Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor. The caudal septum appeared to be now in adequate position. There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place. Following the evaluation of the nose, a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side. Very carefully, the mucoperichondrial flaps were elevated over this, and it was excised using an osteotome taking care to preserve the 1.5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine. Very carefully, the bony cartilaginous junction was identified and a small piece of the bone, where the spur was, was carefully removed. Following this, it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures. Therefore, attention was turned to harvesting the right-sided auricular cartilage, which was done after the region had adequately been prepped and draped in a sterile fashion. Postauricular incision using a #15 blade, the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times. This was very carefully harvested. This area had been injected previously with 1% lidocaine and 1:100,000 epinephrine. Following this, the cartilage was removed. It was placed in saline, noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity. The spreader grafts were sutured in place using submucoperichondrial pockets. After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed, adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery. These were secured in place in the pockets using a 5-0 PDS suture in a mattress fashion in two places. Following this, attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin. Subsequently, the alar rim grafts were placed and extended all the way to the piriform aperture. This was sutured in place using a 5-0 self-absorbing gut suture. The lower lateral cartilage has had some inherent asymmetry. This may have been related to his previous surgery with some asymmetry of the dome; however, this was left in place as he did not desire any changes in the tip region, and there was adequate support. An endodermal suture was placed just to reenforce the region using a 5-0 PDS suture. Following all this, the area was closed using a mattress 4-0 plain gut on a Keith needle followed by the application of ***** 5-0 fast-absorbing gut to close the hemitransfixion incision. Very carefully, the skin and subcutaneous tissue envelopes were reflected. The curvilinear incision was closed using a Vicryl followed by interrupted 6-0 Prolene sutures. The marginal incisions were then closed using 5-0 fast-absorbing gut. Doyle splints were placed and secured down using a nylon suture. They had ointment also placed on them. Following this, nasopharynx was suctioned. There were no further abnormalities noted and everything appeared to be in nice position. Therefore, an external splint was placed after the application of Steri-Strips. The patient tolerated the procedure well. He was awakened in the operating room. He was extubated and taken to the recovery room in stable condition.
## 179 PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.
## 180 OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room. After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray. After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium. After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate. A 45-degree forceps then used to open up the maxillary sinus. There was some prominent tissue and just superior to this, the anterior ethmoid was opened. The 45-degree forceps was then used to open the maxillary sinus ostium. This was enlarged with backbiting rongeur. After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa. After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate. There was noted to have prominence in the anterior ethmoidal area. This was then opened with 45-degree forceps. This mucosa was then removed from the anterior area. The maxillary sinus ostium was then opened with 45-degree forceps. Tissue was removed from this area. This was sent as right maxillary mucosa. After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus. Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally. This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction. After this was completed, a septoplasty was performed. The incision was made with a #15 blade Bard-Parker knife. The flap was then elevated, overlying the spur that was protruding into the right nasal cavity. This was excised with a #15 blade Bard-Parker knife. The tissue was then laid back in position. After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx. , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon. The patient was then awakened and taken to recovery room in good condition.
## 181 TITLE OF OPERATION:,1. Repair of total anomalous pulmonary venous connection.,2. Ligation of patent ductus arteriosus.,3. Repair secundum type atrial septal defect (autologous pericardial patch).,4. Subtotal thymectomy.,5. Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection. Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS: ,1. Total anomalous pulmonary venous connection.,2. Atrial septal defect.,3. Patent ductus arteriosus.,4. Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:, 35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes. Low flow perfusion 32 minutes.,FINDINGS:, Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins. Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence. Nonobstructed ascending vein ligated. Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin. At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position. Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines. The patient was prepped and draped in the usual sterile fashion from chin to groins. A median sternotomy incision was performed. Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw. A subtotal thymectomy was performed. Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle. A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure. Pursestrings were deployed on the ascending aorta on the right. Atrial appendage. The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula. With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie. Systemic cooling was started and the head was packed and iced and systemic steroids were administered. During cooling, traction suture was placed in the apex of the left ventricle. After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping. Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula. The heart was then rotated to the right side and the venous confluence was exposed. It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed. The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture. Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir. A right atriotomy was then performed during the period of circulatory arrest. The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture. The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures. The venous cannula was reinserted. Cardiopulmonary bypass restarted and the aorta cross-clamp was released. The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm. Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains. Venous decannulation was followed by aortic decannulation and administration of protamine sulfate. All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic. With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires. The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case. Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.
## 182 PREOPERATIVE DIAGNOSIS:, Infected sebaceous cyst, right neck.,POSTOPERATIVE DIAGNOSIS:, Infected sebaceous cyst, right neck.,PROCEDURE: , The patient was electively taken to the operating room after obtaining an informed consent. With a combination of intravenous sedation and local infiltration anesthesia, a time-out process was followed and then the patient was prepped and draped in the usual fashion. The elliptical incision was performed around the draining tract. Immediately we fell in to an abscess cavity with a lot of pus and necrotic tissue. All the necrotic tissue was excised together with an ellipse of skin. Hemostasis was achieved with a cautery. The cavity was irrigated with normal saline. At the end of procedure, there was a good size around cavity that was packed with iodoform gauze. One skin suture was grazed for approximation.,A bulky dressing was applied.,The patient tolerated the procedure well. Estimated blood loss was negligible and the patient was sent to Same Day Surgery for recovery.
## 183 PROCEDURE: , Skin biopsy, scalp mole.,INDICATION: ,A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,PROCEDURE NOTE: , The patient's scalp hair was removed with:,1. K-Y jelly.,2. Betadine prep locally.,3. A 1% lidocaine with epinephrine local instilled.,4. A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab. To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound. Hemostasis was controlled. The patient tolerated the procedure.,IMPRESSION:, Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.,PLAN: , The patient will have sutures removed in 10 days.
## 184 SCLERAL BUCKLE OPENING,The patient was brought to the operating room and appropriately identified. General anesthesia was induced by the anesthesiologist. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye. A 360-degree limbal conjunctival peritomy was created with Westcott scissors. Curved tenotomy scissors were used to enter each of the intermuscular quadrants. The inferior rectus muscle was isolated with a muscle hook, freed of its Tenon's attachment and tied with a 2-0 silk suture. The 3 other rectus muscles were isolated in a similar fashion. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.
## 185 PREOPERATIVE DIAGNOSIS:, Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1. Ligation and stripping of left greater saphenous vein to the level of the knee.,2. Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:, None.,BRIEF HISTORY:, This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity. The patient has had painful varicose veins for number of years. He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins. It was recommended that the patient undergo a saphenous vein ligation and stripping. He was explained the risks, benefits, and complications of the procedure including intractable pain. He gave informed consent to proceed.,OPERATIVE FINDINGS:, The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee. Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly. Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE: ,The patient was marked preoperatively in the Preanesthesia Care Unit. The patient was brought to the operating suite, placed in the supine position. The patient underwent general endotracheal intubation. After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline. A diagonal incision was created in the direction of the inguinal crease on the left. A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified. The vein was isolated with a right angle. The vein was followed proximally until a multiple tributary branches were identified. These were ligated with #3-0 silk suture. The dissection was then carried to the femorosaphenous vein junction. This was identified and #0 silk suture was placed proximally and distally and ligated in between. The proximal suture was tied down. Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein. An incision was created at the level of the knee. The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated. The distal end of the vein stripping device was then passed through at its most proximal location. The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity. Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg. Multiple incisions were created with a #15 blade scalpel. The incisions were carried down with electrocautery. Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified. The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed. Additionally, some segments were removed. The stripping approach would be vein stripping device. Multiple branches of the saphenous vein were then ligated and/or removed. Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat. Bleeding was controlled with direct pressure. All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture. The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions. The leg was then wrapped with a sterile Kerlix. Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression. The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition. He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.
## 186 PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:, IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion. The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes. The patient has failed to conservative treatment and desires surgical correction at this time. Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:, After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously. The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection. Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection. After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg. The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot. After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon. Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery. A neurovascular bundle was identified and reflected medially. Laterally the extensor hallucis longus tendon was identified and protected with retraction as well. Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully. The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule. The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree. Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx. Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint. The bone cortex was noted to be intact and in good condition. Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head. In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected. Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well. Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head. Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal. A second 0.45 K-wire was inserted proximally as well. Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral. After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made. This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal. Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone. Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially. The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone. Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction. Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit. The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex. Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved. Intramedullary sludge was noted to exit from the osteotomy cut. Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked. Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap. Following this, a 20 mm full threaded screw was inserted and tightened. Good intramedullary sludge was noted and compression was achieved. Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite. Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted. Based on this, a lateral release was performed. The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace. The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected. Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament. Upon completion of this, the hallux was noted to be in a rectus position with good alignment. The area was then flushed and irrigated with copious amounts of sterile saline. After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture. Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers. The skin was then reapproximated and closed using #5-0 Monocryl suture. Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing. The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg. The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot. The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit. Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain. The patient was also given prescription for clindamycin to be taken 300 mg four times a day. The patient was given surgical shoe and was placed in a posterior sling. The patient was given crutches and instructed to use them for ambulation. The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend. The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office. The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that. The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise. X-rays were taken and the patient was discharged home upon completion of this.
## 187 PROCEDURE IN DETAIL:, After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty. The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. The 4 rectus muscles were looped and isolated using 2-0 silk suture. The retinal periphery was then inspected via indirect ophthalmoscopy.
## 188 PREOPERATIVE DIAGNOSIS:, Sterilization candidate.,POSTOPERATIVE DIAGNOSIS:, Sterilization candidate.,PROCEDURE PERFORMED:,1. Cervical dilatation.,2. Laparoscopic bilateral partial salpingectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 50 cc.,SPECIMEN: , Portions of bilateral fallopian tubes.,INDICATIONS:, This is a 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.,FINDINGS: , On bimanual exam, the uterus is small, anteverted, and freely mobile. There are no adnexal masses appreciated. On laparoscopic exam, the uterus, bilateral tubes and ovaries appeared normal. The liver margin and bowel appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room where general anesthetic was administered. The patient was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion. A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus was then sounded to 7 cm.,The cervix was serially dilated with Hank dilators. A #20 Hank dilator was left in place. The sterile speculum was then removed. Gloves were changed. Attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient's previous scar. The Veress needle was placed and gas was turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. A 11 mm trocar was then placed through this incision and the camera was placed with the above findings noted. Two 5 mm step trocars were placed, one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus. The Endoloop was placed through the left-sided port. A grasper was placed in the suprapubic port and put through the Endoloop and then a portion of the left tube was identified and grasped with a grasper. A knuckle of tube was brought up with the grasper and a #0 Vicryl Endoloop synched down across this knuckle of tube. The suture was then cut using the endoscopic shears. The portion of tube that was tied off was removed using a Harmonic scalpel. This was then removed from the abdomen and sent to Pathology. The right tube was then identified and in a similar fashion, the grasper was placed through the loop of the #0 Vicryl Endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop. The loop was then synched down. The Endoshears were used to cut the suture. The Harmonic scalpel was then used to remove that portion of tube. The portion of the tube that was removed from the abdomen was sent to Pathology. Both tubes were examined and found to have excellent hemostasis. All instruments were then removed. The 5 mm ports were removed with good hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar was removed. The fascia of the infraumbilical incision was reapproximated with an interrupted suture of #3-0 Vicryl. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of Marcaine was injected at the incision site. The vulsellum tenaculum and cervical dilator were then removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of the procedure. The patient was taken to the recovery room in satisfactory condition. She will be discharged home with a prescription for Vicodin for pain and was instructed to follow up in the office in two weeks.
## 189 PREOPERATIVE DIAGNOSIS:, Stage IV necrotic sacral decubitus.,POSTOPERATIVE DIAGNOSIS:, Stage IV necrotic sacral decubitus.,PROCEDURE PERFORMED:, Debridement of stage IV necrotic sacral decubitus.,GROSS FINDINGS: , This is a 92-year-old African-American female who was brought into the office 48 hours earlier with a chief complaint of necrotic foul-smelling wound in the sacral region and upon examination was found to have absolutely necrosis of the fat and subcutaneous tissue in the sacral region approximately 15 cm x 15 cm. A long discussion with the family ensued that it needs to be debrided and then cleaned and then if she cannot keep the stool out of the wound that she will probably need a diverting colostomy.,OPERATIVE PROCEDURE: ,The patient was properly prepped and draped under local sedation. A 0.25% Marcaine was injected circumferentially around the necrotic decubitus. A wide excision and debridement of the necrotic decubitus taken down to the presacral fascia and all necrotic tissue was electrocauterized and removed. All bleeding was cauterized with electrocautery and then a Kerlix stack was then placed and a pressure dressing applied. The patient was sent to recovery in satisfactory condition.
## 190 PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:, Ruptured globe with uveal prolapse OX.,PROCEDURE: ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: , The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.
## 191 PREOPERATIVE DIAGNOSES:,1. Right pelvic pain.,2. Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1. Right pelvic pain.,2. Right ovarian mass.,3. 8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED: ,Laparoscopic right salpingooophorectomy.,ANESTHESIA: ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:, None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass. Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice. Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits. There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:, The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity. The pain persisted despite multiple pain medications given in the Emergency Room. The patient reports positive nausea and vomiting. There was no vaginal bleeding or discharge. There was no fevers or chills. Her cultures done in the Emergency Room were pending. The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic. The uterus and left ovary were within normal limits. There was a positive flow noted to bilateral ovaries on ultrasound. Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:, After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty. She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion. Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above. She was prepped and draped in the usual sterile fashion. A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix. The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field. The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed. The vulsellum tenaculum was removed. The weighted speculum was removed. Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold. The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp. The CO2 was then turned on with unoccluded flow and excellent pressures. This was continued till a normal symmetrical pneumoperitoneum was obtained. Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope. Laparoscopic findings are as noted above. A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization. Then, a grasper was used to untorse the ovary. Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system. The right tube and ovary were amputated and noted to be hemostatic. The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag. The ovary was too large to fit completely into the bag. Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst. This was a clear yellow fluid. Then, the bag was closed and the ovary was removed from the suprapubic port. The suprapubic port did have to be extended somewhat to allow for the removal of the ovary. The trocar and sleeve were then placed back into the port. The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic. The pelvis was clear and clean. ,Pictures were obtained. The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6. Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed. Therefore, the peritoneal surface was noted to be hemostatic. Therefore, the camera was removed. All instruments were removed. The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed. The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6. The right flank area was palpated and there was no facial defect noted. The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion. Dressings were changed. The weighted speculum was removed from the patient's cervix. The cervix noted to be hemostatic. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.
## 192 PREOPERATIVE DIAGNOSES:,1. Radiation cystitis.,2. Refractory voiding dysfunction.,3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1. Radiation cystitis.,2. Refractory voiding dysfunction.,3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,TITLE OF OPERATION: , Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,ANESTHESIA: , General endotracheal with epidural.,INDICATIONS: ,This patient is a 65-year-old white male who in 1998 had a radical prostatectomy. He was initially dry without pads and then underwent salvage radiation therapy for rising PSA. After that he began with episodes of incontinence as well as urinary retention requiring catheterization. One year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy. He had retained staple removed and a diverticulum identified. There were also bladder stones that were lasered and removed, and he had been incontinent ever since that time. He wears 8 to 10 pads per day, and this has affected his quality of life significantly. I took him to the operating room on January 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck. We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him. I felt like if we could remove the bladder safely, then this would also provide a benefit.,FINDINGS: , At exploration, there were no gross lesions of the smaller or large bowel. The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally. The opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment. Because of the previous radiation therapy and a dissection down to the pelvis, I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,PROCEDURE IN DETAIL: ,The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion. A nasogastric tube was placed as well as radial arterial line. He was given intravenous antibiotics for prophylaxis. A generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described. Moist wound towels and a Bookwalter retractor were placed for exposure. We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum. The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips. An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries. This was quite challenging because of the previous radiation therapy and radical prostatectomy. We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally. We then approached things posteriorly and carefully dissected between the __________ and posterior bladder. There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum. We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum. We then peeled it off the remaining rectum and passed the specimen off the operative field. Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,We then completely mobilized the omentum off of the proximal transverse colon. This allowed a generous flap to be able to be laid into the pelvis without tension.,We then turned our attention to forming the Indiana pouch. I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon. The colon was divided proximal to the middle colic using a GIA-80 stapler. I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum. The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler. We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60. The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler. The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy. We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures. The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75. Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis. The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture. The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis. We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture. A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture. The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture. The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis. The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures. We then matured our stoma through the umbilicus. We removed the plug of skin through the umbilicus and delivered the ileal segment through this. A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures. We left an 18-French Robinson through the stomag and secured this to the skin with silk sutures. The Malecot and stents were also secured in a similar fashion.,We matured the stoma to the umbilicus with interrupted chromic stitches. The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant. A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch.,The rectus fascia was closed with a buried #2 Prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia. Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips. The estimated blood loss was 450 mL, and the patient received no packed red blood cells. The final sponge and needle count were reported to be correct. The patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.
## 193 PREOPERATIVE DIAGNOSIS: , Ruptured globe OX.,POSTOPERATIVE DIAGNOSIS:, Ruptured globe OX.,PROCEDURE: , Repair of ruptured globe OX.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS: ,None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.,Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.,At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried. ,Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.
## 194 PREOPERATIVE DIAGNOSIS:, Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION: ,This is a 62-year-old female for the above-planned procedure. She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied. Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table. Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen. This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized. Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty. Markers were applied to both upper lids in symmetrical fashion. The skin was excised from the right upper lid first followed by appropriate muscle resection. Minimal fat removed from the medial upper portion of the eyelid. Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture. Attention was then turned to the lower lid. A classic skin muscle flap was created accordingly. Fat was resected from the middle, medial, and lateral quadrant. The fat was allowed to open drain the arcus marginalis for appropriate contour. Hemostasis was controlled with the pinpoint cautery accordingly. Skin was redraped with a conservative amount resected. Running closure with 7-0 nylon was accomplished without difficulty. The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes. Eye mass was likewise clamped. Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure. The right face was first operated. It was injected with a 0.25% Marcaine 1:200,000 adrenaline. A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula. She had minimal subcutaneous extra fat as noted. Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline. The flap was elevated without difficulty with various facelift scissors. Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision. Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery. The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication. The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene. The skin was draped appropriately and appropriate tissue was resected. A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface. Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon. The hairline temporal incision was closed with running 5-0 nylon. The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described. Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly. Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly. Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure. The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure. She will be discharged in the morning.,Estimated blood loss was less than 75 cc. No complications noted, and the patient tolerated the procedure well.
## 195 PREOPERATIVE DIAGNOSES:,1. Right shoulder rotator cuff tear.,2. Glenohumeral rotator cuff arthroscopy.,3. Degenerative joint disease.,POSTOPERATIVE DIAGNOSES:,1. Right shoulder rotator cuff tear.,2. Glenohumeral rotator cuff arthroscopy.,3. Degenerative joint disease.,PROCEDURE PERFORMED: ,Right shoulder hemiarthroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Approximately 125 cc.,COMPLICATIONS:, None.,COMPONENTS: , A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used.,BRIEF HISTORY: ,The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.,PROCEDURE: , The patient was taken to the operative suite, placed on the operative field. Department of Anesthesia administered general anesthetic. Once adequately sedated, the patient was placed in the beach chair position. Care was ensured that she was well positioned, adequately secured and padded. At this point, the right upper extremity was then prepped and draped in the usual sterile fashion. A deltopectoral approach was used and taken down to the skin with a #15 blade scalpel.,At this point, blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue. Any perforating bleeders were cauterized with Bovie to obtain hemostasis. Once the bursa was seen, it was removed with a Rongeur and subscapular tendon could be easily visualized. At this point, the rotator cuff in the subacromial region was evaluated. There was noted to be a large rotator cuff, which was irreparable. There was eburnated bone on the greater tuberosity noted. The articular surface could be visualized. The biceps tendon was intact. There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface. The under surface of the acromion, it was felt there was mild ware on this as well. At this point, the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture. It was separated from the capsule to have a two layered repair at closure. The capsule was also reflected posterior. At this point, the glenoid surface could be easily visualized. It was evaluated and had good cartilage contact and appeared to be intact. The humeral head was evaluated. There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head. At this point, decision was made to proceed with the arthroplasty, since the rotator cuff tear was irreparable and there was significant ware of the humoral head. The arm was adequately positioned. An oscillating saw was used to make the head articular cut. This was done at the margin of the articular surface with the anatomic neck. This was taken down to appropriate level until this articular surface was adequately removed. At this point, the intramedullary canal and cancellous bone could be easily visualized. The opening hand reamers were then used and this was advanced to a size #10. Under direct visualization, this was performed easily. At this point, the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins. This was then removed. A trial component was then impacted into place, which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured. It did not appear overstuffed with evidence of excellent range of motion and no impingement. At this point, the trial component was removed. Wound was copiously irrigated and suctioned dry. Cement was then placed with a cement gun into the canal and taken up to the level of the cut. The prosthesis was then inserted into place and held under direct visualization. All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself. This _______ cement was adequately hard at this point. The final component of the head was impacted into place, secured on the Morris taper and checked, and this was reduced.,The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position. The wound was again copiously irrigated and suctioned dry. At this point, the capsule was then reattached to its insertion site in the anterior portion. Once adequately sutured with #1-Vicryl, attention was directed to the subscapular. The subscapular was advanced superiorly and anchored not only to the biceps tendon region, but also to the top anterior portion of the greater tuberosity. This was opened to allow some type of coverage points of the massive rotator cuff tear. This was secured to the tissue and interosseous sutures with size #2 fiber wire. After this was adequately secured, the wound was again copiously irrigated and suctioned dry. The deltoid fascial split was then repaired using interrupted #2-0 Vicryl, subcutaneous tissue was then approximated using interrupted #24-0 Vicryl, skin was approximated using a running #4-0 Vicryl. Steri-Strips and Adaptic, 4 x 4s, and ABDs were then applied. The patient was then placed in a sling and transferred back to the gurney, reversed by Department of Anesthesia.,DISPOSITION: , The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition.
## 196 PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1. Sixty-percent rotator cuff tear, joint side.,2. Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1. Arthroscopic subacromial decompression.,2. Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff. The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon. This was confirmed later when the bursal side was opened up. Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion. He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:, He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position. The shoulder was instilled with fluid from posteriorly, followed by the arthroscope. The shoulder was instilled with fluid from posteriorly, followed by the arthroscope. Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope. With the scope in the posterior portal, the above findings were noted, and an anterior portal was established. A curved shaver was placed for debridement of the tear. I established this was about a 60-70% tear with a probable complete area of tear which was very small. There were no problems at the biceps or the rest of the joint. The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur. I did not debride the acromioclavicular joint. The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid. The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed. The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur. Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair. The shoulder was carried through a range of motion. I could see no evidence of impingement. Copious irrigation was carried out. The deltoid deep fascia was anatomically closed, as was the superficial fascia. The subcutaneous tissue and skin were closed in layers. A sterile dressing was applied. The patient appeared to tolerate the procedure well.
## 197 PREOPERATIVE DIAGNOSIS:, Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE: ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.
## 198 PREOPERATIVE DIAGNOSIS: , Right ureteral calculus.,POSTOPERATIVE DIAGNOSIS: , Right ureteropelvic junction calculus.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Right retrograde pyelogram.,3. Right double-J stent placement 22 x 4.5 mm.,FIRST SECOND ANESTHESIA: , General.,SPECIMEN:, Urine for culture and sensitivity.,DRAINS: , 22 x 4.5 mm right double-J ureteral stent.,PROCEDURE: , After consent was obtained, the patient was brought to operating room and placed in the supine position. She was given general anesthesia and then placed in the dorsal lithotomy position. A #21 French cystoscope was then passed through the urethra into the bladder. There was noted to be some tightness of the urethra on passage. On visualization of the bladder, there were no stones or any other debris within the bladder. There were no abnormalities seen. No masses, diverticuli, or other abnormal findings. Attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter, however, the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter. The cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis. An open-end ureteral catheter was then passed ________ into the distal right ureter. Retrograde pyelogram was then performed.,There was noted to be an UPJ calculus with no noted hydronephrosis. The wire was then passed back through the ureteral catheter. The catheter was removed and a 22 x 4.5 mm double-J ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance. The stent was clear within the kidney as well as within the bladder. The bladder was drained and the cystoscope was removed. The patient tolerated the procedure well. She will be discharged home. She is to follow up with Dr. X for ESWL procedure. She will be given prescription for Darvocet and will be asked to have a KUB x-ray done prior to her followup and to bring them with her to her appointment.
## 199 PREOPERATIVE DIAGNOSIS: , Nasal deformity, status post rhinoplasty.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:, Revision rhinoplasty (CPT 30450). Left conchal cartilage harvest (CPT 21235).,ANESTHESIA: , General.,INDICATIONS FOR THE PROCEDURE: , This patient is an otherwise healthy male who had a previous nasal fracture. During his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma. The patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect. The patient was consented for the above-stated procedure. The risks, benefits, and alternatives were discussed.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. The patient did have approximately 12 mL of Lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues. In addition to this, cocaine pledgets were placed to assist with hemostasis.,At this point, attention was turned to the left ear. Approximately 3 mL of 1% Lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb. Betadine was utilized for preparation. A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane. I then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested. These were placed aside in saline. Hemostasis was obtained with bipolar electrocauterization. Bovie electrocauterization was also employed as needed. The entire length of the wound was then closed with 5-0 plain running locking suture. The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 Prolene suture. Antibiotic ointment was applied generously.,Next, attention was turned to opening and lifting the soft tissues of the nose. A typical external columella inverted V gull-wing incision was placed on the columella and trailed into a marginal incision. The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums. Soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum. At this point, attention was turned to osteotomies and examination of the external cartilages.,The patient did have very broad lower lateral cartilages leading to a bulbous tip. The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect. Having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome. These were done transmucosally after elevating the tract using a Cottle elevator. Direct hemostasis pressure was applied to assist with bruising.,Next, attention was turned to tip mechanisms. The patient had a series of double-dome sutures placed into the nasal tip. Then, 5-0 Dexon was employed for intradomal suturing, 5-0 clear Prolene was used for interdomal suturing. Having completed this, a 5-0 clear Prolene alar spanning suture was employed to narrow the superior tip area.,Next, attention was turned to dorsal augmentation. A Gore-Tex small implant had been selected, previously incised. This was taken to the back table and carved under sterile conditions. The patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum. It was placed into a precise pocket and remained in the midline.,Next, attention was turned to performing a columella strut. The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage. This was fixed into position utilizing a 5-0 Dexon suture.,Having completed placement of all augmentation grafts, the patient was examined for hemostasis. The external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures. The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,At the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic. There was no evidence of hematoma, and the patient had a series of brown Steri-Strips and Aquaplast cast placed over the nasal dorsum. The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,The patient was transferred to the PACU in stable condition. He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore-Tex implant area. He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest.
## 200 PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:, Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1. Nasal endoscopy.,2. Partial rhinectomy.,ANESTHESIA:, General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago. He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall. He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip. He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma. The preoperative examination shows induration of the nasal tip without significant erythema. There is focal tenderness just cephalad to the alar crease. There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position. Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin. He was prepped and draped in standard fashion. The left nasal cavity was examined by anterior rhinoscopy. The septum was midline. There was slight asymmetry of the nares. No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor. The 0-degree nasal endoscope was then used to examine the nasal cavity more completely. No lesion was detectable. A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A. The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present. Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section. A diagnosis of diffuse invasive squamous cell carcinoma was rendered. An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery. The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin. The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it. Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins. Additional soft tissue was then taken from all margins tagging them for the pathologist. The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone. A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone. Additional soft tissue was taken in these regions along the superior margin. The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology. Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound. A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla. This was all submitted to pathology for routine permanent examination. Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture. The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well. Sponge and needle counts were correct.
## 201 PREOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,POSTOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,PROCEDURES:,1. Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2. Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,ASSISTANT: , None.,ANESTHESIA: , Attended local by Strickland and Associates.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position. Dressing was removed from the left eye, which revealed the defect as noted above. After systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid. The patient was prepped and draped in the usual ophthalmic fashion. Protective scleral shell was placed in the left eye. A 4-0 silk traction sutures placed through the upper eyelid margin. The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound. The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid. Relaxing incisions were made both medially and laterally and Mueller's muscle was subsequently dissected free from the superior tarsal border. The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 Vicryl sutures and one 4-0 Vicryl suture. The protective scleral shell was removed from the eye. The medial aspect of the eyelid was advanced temporally. The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 Vicryl sutures. The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 Vicryl suture. The upper eyelid wound was present. It was advanced to the advanced tarsoconjunctival pedicle temporally. The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 Vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 Vicryl sutures. Skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 Vicryl sutures. Burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 Vicryl suture. Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 Vicryl suture to the periosteum overlying the lateral orbital rim. The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 Vicryl followed by wound closure temporally with interrupted 7-0 Vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure. Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure. The patient tolerated the procedure well and left the operating room in excellent condition. There were no apparent complications.
## 202 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 weeks.,2. History of previous cesarean section x2. The patient desires a repeat section.,3. Chronic hypertension.,4. Undesired future fertility. The patient desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 weeks.,2. History of previous cesarean section x2. The patient desires a repeat section.,3. Chronic hypertension.,4. Undesired future fertility. The patient desires permanent sterilization.,PROCEDURE PERFORMED: ,Repeat cesarean section and bilateral tubal ligation.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:, 800 mL.,COMPLICATIONS: ,None.,FINDINGS: , Male infant in cephalic presentation with anteflexed head, Apgars were 2 at 1 minute and 9 at 5 minutes, 9 at 10 minutes, and weight 7 pounds 8 ounces. Normal uterus, tubes, and ovaries were noted.,INDICATIONS: ,The patient is a 31-year-old gravida 5, para 4 female, who presented to repeat cesarean section at term. The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section, additionally she desires permanent fertilization. The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and the possible need for further surgery and informed consent was obtained.,PROCEDURE NOTE: , The patient was taken to the operating room where spinal anesthesia was administered without difficulty. The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt. A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using the Bovie. The rectus muscles were dissected in the midline.,The peritoneum was identified and entered using Metzenbaum scissors; this incision was extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was inserted. The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The bladder blade was reinserted. The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction.,Clear fluid was noted. The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant's head without the Kelly. The nose and mouth were bulb suctioned. The cord was clamped and cut. The infant was subsequently handed to the awaiting nursery nurse. The placenta was delivered spontaneously intact with a three-vessel cord noted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was repaired in 2 layers using 0 chromic sutures. Hemostasis was visualized. Attention was turned to the right fallopian tube, which was grasped with Babcock clamp using a modified Pomeroy method, a 2 cm of segment of tube ligated x2, transected and specimen was sent to pathology. Attention was then turned to the left fallopian tube, which was grasped with Babcock clamp again using a modified Pomeroy method, a 2 cm segment of tube was ligated x2 and transected. Hemostasis was visualized bilaterally. The uterus was returned to the abdomen, both fallopian tubes were visualized and were noted to be hemostatic. The uterine incision was reexamined and it was noted to be hemostatic. The pelvis was copiously irrigated. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was closed with 0 Vicryl suture, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
## 203 HISTORY OF PRESENT ILLNESS: ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007. The patient presents with no complaints for cadaveric renal transplant. After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:, Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:, Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS: ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA: ,General endotracheal.,SPECIMEN: ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room, prepped and draped in sterile fashion. After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space. After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat. Camper's and Scarpa's were dissected with electrocautery. Hemostasis was achieved throughout the tissue plains with electrocautery. The external oblique aponeurosis was identified with musculature and was entered with electrocautery. Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia. Additionally, the rectus sheath was entered in a linear fashion. After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection. After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery. Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties. After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane. This was done without any complication and without entering the peritoneum grossly. The round ligament was identified and doubly ligated at this time with #0 silk ties as well. The dissection continued down now to layer of the alveolar tissue covering the right iliac artery. This alveolar tissue was cleared using blunt dissection as well as electrocautery. After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture. The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection. After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well. An additional perforating branch was noted at the inferior pole of the right iliac vein. This was tied with a #0 silk tie and secured. Hemostasis was achieved at this time and the tie had adequate control. The dissection continued down and identified all other vital structures in this area. Careful preservation of all vital structures was carried out throughout the dissection. At this time, Satinsky clamp was placed over the right iliac vein. This was then opened using a #11 blade, approximately 1 cm in length. The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked. The renal vein was then elevated and identified in this area. A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured. The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles. The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles. After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again. After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over. The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow. The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney. The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow. At this time, all Satinsky clamps were removed and all bulldog clamps were removed. The dissection then continued down to the layer of the bladder at which time the bladder was identified. Appropriate area on the dome the bladder was identified for entry. This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion. Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length. At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well. Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder. This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again. Good flow was noted from the ureter at the time of operation. Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself. At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again. This was inspected and noted for proper control. Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects. At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time. The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved. A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior. This was secured and knots were dumped. Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl. The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable. Dr. A was present and scrubbed through the entire procedure.
## 204 PREOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,POSTOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,OPERATION PERFORMED: ,Removal of venous port.,ANESTHESIA: , General.,INDICATIONS: , This 9-year-old young lady presented with ALL in Orange County and had a port placed at that time. She subsequently has now undergone chemotherapy here and is now off therapy. She no longer needs her venous port so, comes to the operating room today for its removal.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the exit site was prepped and draped in usual manner. The previous incision was opened by excising the old scar. The port pocket was then opened and the port was removed from the pocket. There was a resistance to the catheter being removed and so therefore, we began following the catheter along its path opening the tract until finally the catheter seemed to come free and could be pulled out without difficulty. The port pocket was then closed using a #3-0 Vicryl in subcutaneous tissue, #5-0 subcuticular Monocryl in the skin. Sterile dressing was applied. Young lady was awakened and taken to the recovery room in satisfactory condition.
## 205 PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643). Excision of tumor from the skull with debridement of the superficial cortex with diamond bur. Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).,ANESTHESIA:, General endotracheal anesthesia.,INDICATIONS: ,This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma. This appears to be affixed to the underlying scalp.,PLAN: , Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.,CONSENT:, I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.,FINDINGS: , The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull. The final periosteal margin which centrally appeared was positive for carcinoma. The final margins peripherally were all negative.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was taken to the operating room and there was placed supine on the operating room table.,General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel. The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint. Thereafter, the local anesthesia was injected into the area around the tumor. A **** type excision was planned down to the periosteum. A supraperiosteal radical resection was performed.,It was obvious that there was tumor at the deep margin, involving the periosteum. The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation. Frozen section revealed positive margins at one end of the resection. Therefore, an additional circumferential resection was performed and the final margins were all negative.,Following completion, the deep periosteal margin was resected. The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull. Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located. Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area. Therefore, no bong margin was taken. However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.,Following completion of the bony resection, the area was irrigated with copious amounts of saline. Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm. The galea was incised in multiple areas, to provide for additional mobilization of the tissue. The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.,The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.,DISPOSITION:, The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.,NOTE: , The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor. The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.
## 206 PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side.,2. Interpretation of Radiograph.,ANESTHESIA: ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATIONS: , Patient with reflex sympathetic dystrophy, left side. Positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,SUMMARY OF PROCEDURE: , Patient is admitted to the Operating Room. Monitors placed, including EKG, Pulse oximeter, and BP cuff. Patient had a pillow placed under the shoulder blades. The head and neck was allowed to fall back into hyperextension. The neck region was prepped and draped in sterile fashion with Betadine and alcohol. Four sterile towels were placed. The cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally. A 22 gauge SMK 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially. The needle is advanced prudently through the tissues, avoiding the carotid artery laterally. The tip of the needle is perceived to intersect with the vertebral body of Cervical #7 and this was visualized by fluoroscopy. Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand. No venous or arterial blood return is noted. No cerebral spinal fluid is noted. Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 Hz. After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% Marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region. This was done with intermittent aspiration vigilantly verifying negative aspiration. The stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade. This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion. The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution. Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band-Aid was placed over the puncture site. Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae. Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion. ,Interpretation of radiograph reveals placement of the 22-gauge SMK 5-mm bare tipped needle in the region of the stellate ganglion on the affected side. Four lesions were carried out.
## 207 PREOPERATIVE DIAGNOSES:,1. Nasal obstruction secondary to deviated nasal septum.,2. Bilateral turbinate hypertrophy.,PROCEDURE:, Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: ,The patient is a 26-year-old white female with longstanding nasal obstruction. She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose. From her functional standpoint, she has severe left-sided nasal septal deviation with compensatory inferior turbinate hypertrophy. From the aesthetic standpoint, the nose is over projected, lacks rotation, and has a large dorsal hump. First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump, rotate the tip of the nose, and de-project the nasal tip. I explained to her the risks, benefits, alternatives, and complications for postsurgical procedure. She had her questions asked and answered and requested that we proceed with surgery as outlined above.,PROCEDURE DETAILS: , The patient was taken to the operating room and placed in supine position. The appropriate level of general endotracheal anesthesia was induced. The face, head, and neck were sterilely prepped and draped. The nose was anesthetized and vasoconstricted in the usual fashion. Procedure began with a left hemitransfixion incision, which was brought down into the left intercartilaginous incision. Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane. Intact bilateral septomucoperichondrial flaps were elevated and a severe left-sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline. Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed. Anterior and inferior one-third of each inferior turbinate was clamped, cut, and resected. The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm. The bony hump of the nose was lowered with a straight osteotome by 4 mm. Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose. The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip. The caudal septum was shortened by 2 mm in an angle in order to enhance rotation. Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of #3-0 chromic. The upper lateral cartilages were rejoined to the dorsal septum with a #4-0 plain gut suture. No middle valves or bone grafts were necessary. Intact mucoperichondrial flaps were closed with 4-0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum. The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol. Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room, taken to the recovery room in good condition.
## 208 PREOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,POSTOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,PROCEDURE PERFORMED:, Release of A1 pulley, right thumb.,ANESTHESIA:, IV regional with sedation.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Approximately 20 minutes at 250 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,HISTORY: ,This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb. She was actually able to spontaneously trigger the thumb. She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley. All risks and benefits of the surgery was discussed with her at length. She was in agreement with the above treatment plan.,PROCEDURE: ,On 08/21/03, she was taken to operating room at ABCD General Hospital and placed supine on the operating table. A regional anesthetic was applied by the Anesthesia Department. Tourniquet was placed on her proximal arm. The upper extremity was sterilely prepped and draped in the usual fashion.,An incision was made over the proximal crease of the thumb. Subcuticular tissues were carefully dissected. Hemostasis was controlled with electrocautery. The nerves were identified and retracted throughout the entire procedure. The fibers of the A1 pulley were identified. They were sharply dissected to release the tendon. The tendon was then pulled up into the wound and inspected. There was no evidence of gross tear noted. Fibrous nodule was noted within the tendon itself. There was no evidence of continuous locking. Once release of the pulley had been performed, the wound was copiously irrigated. It was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures. Sterile dressing was applied to the upper extremity. Tourniquet was deflated. It was noted that the thumb was warm and pink with good capillary refill. The patient was transferred to Recovery in apparent stable and satisfactory condition. Prognosis is fair.
## 209 PREOPERATIVE DIAGNOSIS:, Congenital bilateral esotropia, 42 prism diopters.,PROCEDURE:, Bilateral rectus recession with the microscopic control, 8 mm, both eyes.,POSTOPERATIVE DIAGNOSIS: , Congenital bilateral esotropia, 42 prism diopters.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , The patient was taken to the Surgery Room and placed in the supine position. The general anesthesia was achieved with intubation with no problems. Both eyes were prepped and draped in usual manner. The attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape. The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem. The eyeball rotated medially and upwards by holding the limbus at 7 o'clock position. Inferior fornix conjunctival incision was made and Tenons capsule buttonholed. The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook. The Tenons capsule was buttonholed. The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle. __________ extension of the muscle was excised. The 7-0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders. The muscle was disinserted from original insertion. The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion. The suture was pulled, tied, and cut. The muscle was in good position. The conjunctiva was closed with 7-0 Vicryl suture in running fashion. The suture was pulled, tied, and cut. The eye speculum was taken out.,Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion. The suture was pulled, tied and cut. The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut. TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition. To be seen in the office in 1 week.
## 210 PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:, Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:, General LMA.,TOURNIQUET TIME: ,9 minutes at 200 torr.,FINDINGS:, The patient was found to have limitations to extension at the IP joint to the right thumb. He was found to have full extension after release of A1 pulley.,INDICATIONS:, The patient is 2-1/2-year-old. He has a history of a trigger thumb. This was evaluated in the office. He was indicated for release of A1 pulley to allow for full excursion. Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family. They wanted to proceed.,PROCEDURE:, The patient was brought into the operating room and placed on the operating table in supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. The right upper extremity was then prepped and draped in a standard fashion. Limb was exsanguinated with an Esmarch bandage. Tourniquet was raised to 200 torr. Transverse incision was then made at the base of thumb. The underlying soft tissues were carefully spread in line longitudinally. The underlying tendon was then identified. The accompanied A1 pulley was also identified. This was incised longitudinally using #11 blade. Inspection of the entire tendon then demonstrated good motion both in flexion and extension. The leaflets of the pulley were easily identified.,The wound was then irrigated and closed. The skin was closed using interrupted #4-0 Monocryl simple sutures. The area was injected with 5 mL of 0.25% Marcaine. The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban. The patient was awakened from anesthesia and taken to the recovery room in good condition. There were no complications. All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home. He will return in 1-1/2 weeks for wound inspection.
## 211 PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:, Radioactive plaque macular edema.,TITLE OF OPERATION:, Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure. Then a retrobulbar injection of 2% Xylocaine was performed. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed. Next, the plaque was identified and the two scleral sutures were removed. The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture. The fundus was inspected with direct ophthalmoscopy. An eye patch was applied following Neosporin solution irrigation. The patient was sent to the recovery room in good condition. A lateral canthotomy had been done.
## 212 PREOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,POSTOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,PROCEDURE:, CPT code 57307 - Closure of rectovaginal fistula, transperineal approach.,MATERIAL FORWARDED TO THE LABORATORY FOR EXAMINATION:, Includes fistula tract.,ESTIMATED BLOOD LOSS:, 25 mL.,INDICATIONS:, The patient is a 27-year-old morbidly obese gravida three, para one, who was seen in consultation from Dr. M's office, in the office of Chattanooga GYN Oncology on 01/12/06 regarding an obstetrically related rectovaginal fistula, dating from 1998. She had an episioproctotomy associated with the birth of her seven pound son in 1998 and immediately noted the spontaneous loss of gas and stool. She had her fistula repaired by Dr. R in 2000 and did well for approximately one year, without complaint, when she again noted the spontaneous loss of stool and gas from her vagina. She has partial control if her stools are formed, but she has no control of her gas. She is a type 2 diabetic, with poorly controlled blood sugars at times, however, her diabetes has been fairly well controlled of late.,FINDINGS AT THE TIME OF SURGERY:, She had a 1 cm fistulous tract, approximately 4 cm proximal to the vaginal introitus. This communicated directly with the low rectal vault. She had good rectal sphincter tone and a very thin perineal body. The fistulous tract was excised completely and intact. The underlying rectal mucosa was closed with chromic and the perineal body was reinforced and reconstructed. At the completion of the procedure, the repair is watertight, there were no other defects.,DESCRIPTION OF THE OPERATION:, The patient was taken to the operating room where she underwent general endotracheal anesthesia. She was then placed in the lithotomy position using candy-cane stirrups. The vulva and vagina were prepped and the patient was draped. A lacrimal duct probe was used to define the fistulous tract and a transperineal incision was made. The rectovaginal septum was developed and with an index finger in the rectum, the rectovaginal septum was easily defined. The fistulous tract was isolated and using the lacrimal duct probe, it was completely isolated. Using electrocautery dissection on the pure cut mode, the rectal mucosa was entered in a circumferential fashion as was the vaginal mucosa. This allowed for removal of the fistulous tract intact, with both epithelial layers preserved. The perineum and rectum were irrigated vigorously and then the rectal mucosa was reapproximated with a running stitch of number 4-0 chromic. The rectal vault was distended with saline and the repair was watertight. The defect was irrigated, suctioned, inspected and found to be free of clot, blood or debris. The perineal body was reconstructed with reapproximation of the levator muscles, using a series of interrupted horizontal mattress stitches of number 2-0 Vicryl. This allowed for excellent restoration of the perineal body. After this was accomplished, the defect was once again irrigated, suctioned, inspected, and found to be free of clot, blood or debris. The vaginal defect was closed with a running locking stitch of number 2-0 Vicryl and the perineal incision was closed with a subcuticular stitch of number 2-0 Vicryl. The patient was awakened and taken to the recovery room in stable condition, after having tolerated the procedure well.
## 213 PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA: ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room in the prone position. The back prepped with Betadine. The patient was given sedation and monitored. Under fluoroscopy, the right sacral alar notch was identified. After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained. Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected. Coagulation was then carried out at 90oC for 90 seconds. The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint. Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications. The patient was returned to outpatient recovery in stable condition.
## 214 PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: ,INT was placed. The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion. The patient was given sedation and monitored. Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body. A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body. At this time a negative motor stimulation was obtained. Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds. At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated. This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated. There were no compilations from this. The patient was discharged to operating room recovery in stable condition.
## 215 PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3. Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement. Motor stimulation was applied at 2 Hz with 1 millisecond duration. No extremity movement was noted at less than 2 volts. Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue. After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.
## 216 PROCEDURE PERFORMED: , Modified radical mastectomy.,ANESTHESIA: , General endotracheal tube.,PROCEDURE: ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner. Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury.,An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site. The skin incision was carried down to the subcutaneous fat but no further. Using traction and counter-traction, the upper flap was dissected from the chest wall medially to the sternal border, superiorly to the clavicle, laterally to the anterior border of the latissimus dorsi muscle, and superolaterally to the insertion of the pectoralis major muscle. The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi. Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2-0 Vicryl. The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely. Once the lateral border of the pectoralis major muscle was identified, the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen.,The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein. The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist. The axilla was then cleared of its contents by sharp dissection. Small vessels entering the axillary vein were clipped and divided. The axilla was cleared down to the chest wall, and dissection was continued laterally to the subscapular vein. The long thoracic nerve was cleared identified lying against the chest and was carefully preserved. The long thoracic nerve represented the posterior most aspect of the dissection. As the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved. The dissection continued caudally until the entire specimen was freed and delivered from the operative field. Copious water lavage was used to remove any debris, and hemostasis was obtained with Bovie electrocautery.,Two Jackson-Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit. The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major. These were secured to the skin using 2-0 silk, which was Roman-sandaled around the drain.,The skin incision was approximated with skin staples. A dressing was applied. The drains were placed on "grenade" suction. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
## 217 PREOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,OPERATION PERFORMED:, Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE: ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room. She underwent general endotracheal anesthetic. The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. The recent biopsy site was located in the upper and outer quadrant of left breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. The dissection was started medially and extended laterally towards the left axilla. The breast was removed and then the axillary contents were dissected out. Left axillary vein and artery were identified and preserved as well as the lung _____. The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. Hemostasis had been achieved with Hemoclips. Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips. The drains were sutured to the chest wall with 3-0 nylon sutures. Dressing was applied and the procedure was completed. The patient went to the recovery room in stable condition.
## 218 PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:, Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,PROCEDURE: ,Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,ANESTHESIA: ,General endotracheal anesthetic with a caudal block x2.,FLUIDS RECEIVED: ,1000 mL crystalloid.,ESTIMATED BLOOD LOSS: ,Less than 10 mL.,SPECIMENS: , Tissue sent to pathology is a renal biopsy.,ABNORMAL FINDINGS: , A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,TUBES AND DRAINS: ,A 10-French silicone Foley catheter with 3 mL in balloon and a 4.7-French ureteral double J-stent multilength.,INDICATIONS FOR OPERATION: ,The patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by Dr. Chang. It was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction. Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,DESCRIPTION OF OPERATION: ,The patient was taken to the operative room. Surgical consent, operative site, and patient identification were verified. Dr. X and Dr. Y both agreed upon the procedures in advance. Dr. Y then, once the patient was anesthetized, requested IV antibiotics with Fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position. Dr. Y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 French. The 9.5-French cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis. I was able to locate the ureteral orifice bilaterally, although no urine coming from the right. We then placed a 4-French ureteral catheter into the ureter as far as we could go. An antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter. A retrograde was performed, and it was found that there was a narrowed band across the two. Upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all. Dr. Y then placed a 0.035 guidewire into the ureter after removing the 4-French catheter and then placed a 4.7-French double-J catheter into the ureter as far as it would go allowing it to coil in the bladder. Once this was completed, we then removed the cystoscope and sheath, placed a 10-French Foley catheter, and the patient was positioned by Dr. X and Dr. Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll. He was then sterilely prepped and draped. Dr. Y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr. X performed cautery of the areas advanced to be excised. Once this was then dissected, Dr. Y and Dr. X divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________. At this point, Dr. X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia. Dr. Y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum. Dr. X and Dr. Y also needed dissection on the medial and lateral aspects with Dr. Y being on the lateral aspect of the area and Dr. X on the medial to get an adequate length of this. The tissue was markedly inflamed and had significant adhesions noted. The patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction. Ultimately, Dr. Y and Dr. X both with alternating dissection were able to dissect the renal pelvis to a position where Dr. Y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter. Dr. X then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture. Dr. Y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder. Dr. Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed. Dr. Y then placed interrupted sutures of 5-0 Monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair. Dr. X then was able to without much difficulty do interrupted sutures on the medial aspect. The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr. Y and Dr. X closed the ureteropelvic junction without any evidence of leakage. Once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position. This opening was at least 1.5 cm wide. Dr. Y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health. Electrocautery was used on the base. There was no bleeding, however, and the tissue was quite soft. Dermabond and Gelfoam were placed, and then Dr. Y closed the biopsy site over with thrombin-Gelfoam using the 2-0 chromic stay sutures. Dr. X then closed the fascial layers with running suture of 3-0 Vicryl in 3 layers. Dr. Y closed the Scarpa fascia and the skin with 4-0 Vicryl and 4-0 Rapide respectively. A 4-0 nylon suture was then placed by Dr. Y around the previous nephrostomy tube, which was again left clamped. Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr. Y over the nephrostomy tube site, which was left clamped, and the patient then had a Foley catheter placed in the bladder. The Foley catheter was then taped to his leg. A second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.
## 219 PREOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,POSTOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,OPERATION PERFORMED:, Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Radical vulvectomy, right and left superficial and deep inguinal lymph nodes. ,INDICATIONS FOR PROCEDURE: , The patient recently presented with a new vaginal nodule. Biopsy was obtained and revealed squamous carcinoma. The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3/Nx/Mx on clinical examination. Of note, past history is significant for pelvic radiation for cervical cancer many years previously.,FINDINGS: , The examination under anesthesia revealed a 1.5 cm nodule of disease extending slightly above the hymeneal ring. There was no palpable lymphadenopathy in either inguinal node region. There were no other nodules, ulcerations, or other lesions. At the completion of the procedure there was no clinical evidence of residual disease.,PROCEDURE:, The patient was brought to the Operating Room with an IV in place. She was placed in the low anterior lithotomy position after adequate anesthesia had been induced. Examination under anesthesia was performed with findings as noted, after which she was prepped and draped. The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament. Camper's fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary. The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis. The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial. The cribriform fascia was isolated and dissected with preservation of the femoral nerve. The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments. The medial lymph node bundle was isolated, and Cloquet's node was clamped, divided, and ligated bilaterally. The saphenous vessels were identified and preserved bilaterally. The inferior margin of the specimen was ligated, divided, and removed. Inguinal node sites were irrigated and excellent hemostasis was noted. Jackson-Pratt drains were placed and Camper's fascia was approximated with simple interrupted stitches. The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.,Attention was turned to the radical vulvectomy specimen. A marking pen was used to outline the margins of resection allowing 15-20 mm of margin on the inferior, lateral, and anterior margins. The medial margin extended into the vagina and was approximately 5-8 mm. The skin was incised and underlying adipose tissue was divided with electrocautery. Vascular bundles were isolated, divided, and ligated. After removal of the specimen, additional margin was obtained from the right vaginal side wall adjacent to the tumor site. Margins were submitted on the right posterior, middle, and anterior vaginal side walls. After removal of the vaginal margins, the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2-0 Vicryl suture. The skin was closed with interrupted horizontal mattress stitches using 3-0 Vicryl suture. The final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
## 220 PREOPERATIVE DIAGNOSIS:, Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:, Worrisome skin lesion, left hand.,PROCEDURE:, The patient gave informed consent for his procedure. After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest. There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma. A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included. The predominant portion of the biopsy was of the lesion itself.,Lesion was removed. Attention was turned toward the area. Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture. All counts were correct. The procedure was closed. A sterile dressing was applied. There were no complications. The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,
## 221 HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare. This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon. Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy. On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon. He has been followed conservatively since that time. A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg. Right coronary artery to pulmonary artery fistula was also appreciated. The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:, The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted. The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries. This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION:, Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with no evidence of intracardiac shunt. Left-sided heart was fully saturated. Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Right ventricular systolic pressure was mildly elevated at 45% systemic level. There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries. Phasic branch pulmonary artery pressures were normal. Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency. The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation. There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus. The pulmonary valve appeared to be thin and moved well. The median branch pulmonary arteries were of good size with normal distal arborization. Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1. Membranous pulmonary atresia.,2. Atrial septal defect.,3. Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS): ,1. Pulmonary valvotomy surgical.,2. Aortopulmonary artery central shunt.,3. Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES: ,1. Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2. Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3. Small right coronary artery to main pulmonary fistula.,4. Static encephalopathy.,5. Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference. Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated. Conservative outpatient management is to be recommended. Further patient care will be directed by Dr. X.
## 222 PREOPERATIVE DIAGNOSIS:, Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:, Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,INDICATIONS FOR PROCEDURE:, The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted. She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,FINDINGS: , During the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments. During the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap. There was no evidence of intraperitoneal spread or lymphadenopathy. ,OPERATIVE PROCEDURE: ,The patient was brought to the Operating Room with an IV in place. Anesthetic was administered after which she was examined under anesthesia. The vagina was then prepped and a Foley catheter was placed. She was prepped and draped. A Pfannenstiel incision was made three centimeters above the symphysis pubis. The peritoneum was entered and the abdomen was explored with findings as noted. The Bookwalter retractor was placed, and bowel was packed. Clamps were placed on the broad ligament for traction. The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments. The round ligaments were isolated, divided and ligated. The peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection. The pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension. The utero-ovarian ligaments were then isolated, divided and doubly ligated. Tubes and ovaries were mobilized. The ureters were dissected free from the medial leaf of the peritoneum. When the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated. The uterine artery pedicle was dissected anteriorly over the ureter. The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated. This was continued until the insertion point of the ureter into the bladder trigone. The peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened. Clamps were placed on the uterosacral ligaments at their point of origin. Tissues were divided and suture ligated. Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated. The vagina was then clamped and divided at the junction between the middle and upper third. The vaginal vault was closed with interrupted figure-of-eight stitches. Excellent hemostasis was noted.,Retractors were repositioned in the retroperitoneum for the lymphadenectomy. The borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially. The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection. Ligaclips were applied where necessary. After removal of the lymph node specimens, the pelvis was irrigated. The ovaries were transposed above the pelvic brim using running stitches. Packs and retractors were removed, and peritoneum was closed with a running stitch. Subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture. Subcutaneous adipose was irrigated, and Scarpa's fascia was closed with a running stitch. Skin was closed with a running subcuticular stitch. Final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
## 223 PROCEDURES:,1. Robotic-assisted pyeloplasty.,2. Anterograde right ureteral stent placement.,3. Transposition of anterior crossing vessels on the right.,4. Nephrolithotomy.,DIAGNOSIS:, Right ureteropelvic junction obstruction.,DRAINS:,1. Jackson-Pratt drain times one from the right flank.,2. Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1. Renal pelvis.,2. Kidney stones.,INDICATIONS: ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries. Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL: ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out. After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated. Great care was taken to pad all pressure points and a right arm hanger was used. The patient was flexed slightly, and a kidney rest was used. Sequential compression devices were also placed. Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine. Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test. A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas. Next, a 12-mm camera port was placed near the umbilicus. The camera was inserted, and no bowel injury was seen. Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed. The robot was docked and the instruments passed through respective checks. Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially. Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum. At this point, the right kidney was in clear view, and the fascia was entered. Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection. It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole. These arteries were dissected carefully and vessel loops were applied. Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out. The pyelotomy was extended so that the renal collecting system could be directly inspected. Sequentially, each major calyx was inspected under direct vision and irrigated. A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient. At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis. The proximal ureter was spatulated using cold scissors. Next, redundant renal pelvis was excised using cold scissors and sent for permanent section. We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion. 3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis. Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures. Before final stitches were placed, a 6x28 ureteral stent was placed anterograde. This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter. This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision. Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures. Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis. Good pulsation was verified by direct vision proximal and distal to these pexy sutures. Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum. Hemostasis appeared excellent at this point. There was no obvious urine extravasation. At this time, the procedure was terminated. The robot was undocked. Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion. Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this. Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision. The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.
## 224 PROCEDURE:, Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, The area around the lesion was anesthetized after she gave consent for her procedure. Punch biopsy including some portion of lesion and normal tissue was performed. Hemostasis was completed with pressure holding. The biopsy site was approximated with non-dissolvable suture. The area was hemostatic. All counts were correct and there were no complications. The patient tolerated the procedure well. She will see us back in approximately five days.,
## 225 PREOPERATIVE DIAGNOSIS:, Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS: ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: ,The patient was prepped and draped in the usual manner for a local eye procedure. Initially, a 5 cc retrobulbar injection of 2% Xylocaine was done. Then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus. A 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed. The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron. The placement was confirmed with indirect ophthalmoscopy. Next, the eye was irrigated with Neosporin and the conjunctiva was closed with 6-0 plain catgut. The intraocular pressure was found to be within normal limits. An eye patch was applied and the patient was sent to the Recovery Room in good condition. A lateral canthotomy had been done.
## 226 PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1. Radical retropubic prostatectomy, robotic assisted.,2. Bladder suspension.,ANESTHESIA:, General by intubation.,The patient understands his diagnosis, grade, stage and prognosis. He understands this procedure, options to it and potential benefits from it. He strongly wishes to proceed. He accepts all treatment-associated risks to include but not be limited to bleeding requiring transfusion; infection; sepsis; heart attack; stroke; bladder neck contractures; need to convert to an open procedure; urinary fistulae; impotence; incontinence; injury to bowel/rectum/bladder/ureters, etc.; small-bowel obstruction; abdominal hernia; osteitis pubis/chronic pelvic pain, etc.,DESCRIPTION OF THE CASE: ,The patient was taken to the operating room, given a successful general anesthetic, placed in the lithotomy position, prepped with Betadine solutions and draped in the usual sterile fashion. My camera ports were then placed in the standard fan array. A camera port was placed in the midline above the umbilicus using the Hasson technique. The balloon port was placed, the abdomen insufflated, and all other ports were placed under direct vision. My assistant was on the right. The patient was then placed in the steep Trendelenburg position, and the robot brought forward and appropriately docked.,I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis. This nicely exposed the space of Retzius. I then defatted the anterior surface of the prostate and endopelvic fascia.,The endopelvic fascia was then opened bilaterally. The levator ani muscles were carefully dissected free from the prostate and pushed laterally. Dissection was continued posteriorly toward the bundles and caudally to the apex. The puboprostatic ligaments were then transected. A secure ligature of 0 Vicryl was placed around the dorsal venous complex.,I then approached the bladder neck. The anterior bladder neck was transected down to the level of the Foley catheter, which was lifted anteriorly in the wound. I then transected the posterior bladder neck down to the level of the ampullae of the vas. The ampullae were mobilized and transected. These were lifted anteriorly in the field, exposing the seminal vesicles, which were similarly mobilized. Hemostasis was obtained using the bipolar Bovie.,I then identified the Denonvilliers fascia, and this was incised sharply. Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles. I was able to then identify the pedicles over the seminal vesicles, which were hemoclipped and transected.,The field was then copiously irrigated with sterile water. Hemostasis was found to be complete. I then carried out a urethrovesical anastomosis. This was accomplished with 3-0 Monocryl ligatures. Two of these were tied together in the midline. They were placed at the 6 o'clock position, and one was run in a clockwise and the other in a counterclockwise direction to the 12 o'clock position where they were securely tied. A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation. The patient was given indigo carmine, and there was prompt blue urine in the Foley., ,I then carried out a bladder suspension. This was done in hopes of obtaining early urinary control. This was accomplished with 0 Vicryl ligatures. One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis. This nicely re-retroperitonealized the bladder.,The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision. A JP drain was brought in through the 4th arm port and sutured to the skin with 2-0 silk. The camera port fascia was closed with running 0 Vicryl. The skin incisions were closed with a running, subcuticular 4-0 Monocryl.,The patient tolerated the procedure very well. There were no complications. Sponge and instrument counts were reported correct at the end of the case.
## 227 PREOPERATIVE DIAGNOSIS:, Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:, This is a 66-year-old gentleman who had an elevated PSA of 5. His previous PSAs were in the 1 range. TRUS biopsy revealed 4+3 Gleason score prostate cancer with a large tumor burden. After extensive counseling, the patient elected for retropubic radical prostatectomy. Given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision. The patient consented and agreed to proceed forward.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room here. Time out was taken to properly identify the patient and procedure going to be done. General anesthesia was induced. The patient was placed in the supine position. The bed was flexed distant to the pubic area. The patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with Hibiclens soap for three minutes. The patient was then prepped and draped in normal sterile fashion. Foley catheter was inserted sterilely in the field. Preoperative antibiotics were given within 30 minutes of skin incision. A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus. Dissection was taken down through Scarpa's fascia to the level of the anterior rectus sheath. The rectus sheath was then incised and the muscle was split in the middle. Space of rectus sheath was then entered. The Bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area. The lymph node packet on the left side was then dissected. This was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein. Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall. The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally. Care was taken to avoid injury to the nerves. An accessory obturator vein was noted and was ligated. The same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation. The bladder subsequently was retracted cephalad. The prostate was then defatted up to the level of the endopelvic fascia. The endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments. Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders. A Babcock was then applied around the dorsal venous complex over the urethra and the K-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle. A 0-Vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis. Using a knife on a long handle, the dorsal venous complex was then incised using the K-wire as a guide. Following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the Foley catheter. The 3-0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra. The lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end. The catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end. The urethra was subsequently divided in its entirety. A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex. The prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut. Please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue. Throughout the case, the bleeding was controlled with the aid of a clips, Vicryl sutures, silk sutures, and ties, direct pressure packing, and FloSeal. Following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete. Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers' fascia. The seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the Denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip. Care was taken throughout the posterior dissection to preserve the integrity of the ureters. The anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate. Following the dissection, the 5-French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity. Following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation. The bladder neck was then repaired using Vicryl in a tennis racquet fashion. The rest of the mucosa was then everted. The ureteral orifices and ureters were protected throughout the procedure. At this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position. Hemostasis was then adequately obtained. FloSeal was applied to the pelvis. The bladder was then irrigated. It was draining pink urine. The wound was copiously irrigated. The fascia was then closed using a #1 looped PDS. The skin wound was then irrigated, and the skin was closed with a 4-0 Monocryl in subcuticular fashion. At this point, the procedure was terminated with no complications. The patient was then extubated in the operating room and taken in stable condition to the PACU. Please note that during the case about 3600 mL of blood was noted. This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.
## 228 PREOPERATIVE DIAGNOSIS: ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATION PERFORMED:, Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:, 250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate. Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Injury to the adjacent viscera.,6. Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room. Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty. The patient was shaved, prepped, and draped using the usual sterile technique. A sterile 16-French Foley catheter was then placed with clear urine drained. A midline infraumbilical incision was performed by using a #10 scalpel blade. The rectus fascia and the subcutaneous space were opened by using the Bovie. Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly. A Bookwalter retractor was then placed. The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected. Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy. The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors. Opening was enlarged by using sharp dissection. Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device. The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures. The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion. With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie. Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors. The urethra could then be easily identified. Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors. This exposed the blue Foley catheter. Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture. Six of these were placed evenly spaced out anteriorly to posteriorly. The Foley catheter was then removed. This allowed for better traction of the prostate laterally. Lateral pelvic fascia was opened bilaterally. This effectively released the neurovascular bundle from the apex to the base of the prostate. Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat. The prostate was then dissected from laterally to medially from this opening in the perirectal fat. The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate. Maximal length of ureteral stump was preserved. The prostate was carefully lifted cephalad by using gentle traction with fine forceps. The prostate was easily dissected off the perirectal fat using sharp dissection only. Absolutely, no traction to the neurovascular bundle was evident at any point in time. The dissection was carried out easily until the seminal vesicles could be visualized. The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side. The bladder neck was then dissected out by using a bladder neck dissection method. Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy. Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles. This was developed without any difficulty. Both vas deferens were identified, hemoclipped and transected. The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis. About two-thirds of the seminal vesicles were able to be removed. The tip was left behind. Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected. This was performed on the left side and then the right side. This completely freed the prostate. The prostate was sent for permanent section. The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures. The mucosa of the bladder neck was everted by using 4-0 chromic sutures. Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature. The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures. The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck. This was performed by using a French ***** needle. A 20-French Foley catheter was then inserted and the sutures were sequentially tied down. A 15 mL of sterile water was inflated to balloon. The bladder anastomosis to the urethra was performed without any difficulty. A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region. All instrument counts, lap counts, and latex were verified twice prior to the closure. The rectus fascia was closed in running fashion using #1 PDS. Subcutaneous space was closed by using 2-0 Vicryl sutures. The skin was reapproximated by using metallic clips. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
## 229 PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA: ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies. He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Deep venous thrombosis.,6. Recurrence of the cancer.,PROCEDURE IN DETAIL: , Epidural anesthesia was administered by the anesthesiologist in the holding area. Preoperative antibiotic was also given in the preoperative holding area. The patient was then taken into the operating room after which general LMA anesthesia was administered. The patient was shaved and then prepped using Betadine solution. A sterile 16-French Foley catheter was inserted into the bladder with clear urine drain. A midline infraumbilical incision was performed. The rectus fascia was opened sharply. The perivesical space and the retropubic space were developed bluntly. Bookwalter retractor was then placed. Bilateral obturator pelvic lymphadenectomy was performed. The obturator nerve was identified and was untouched. The margin for the resection of the lymph node bilaterally were the Cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder. Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips. The lymph nodes were palpably normal and were set for permanent section. The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors. The puboprostatic ligament was taken down sharply. The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2-0 silk sutures. The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area. The dorsal vein complex was ligated by using 0 Vicryl suture on a CT-1 needle. The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors. The urethra was then identified and was dissected out. The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors. This was extended circumferentially until the Foley catheter could be seen clearly. 2-0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later. The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected. The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides. The plane between Denonvilliers' fascia and the perirectal fat was developed sharply. No tension was placed on the neurovascular bundle at any point in time. The prostate dissected off the rectal wall easily. Once the seminal vesicles were identified, the fascia covering over them were opened transversely. The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected. The bladder neck was then dissected out carefully to spare most of the bladder neck muscles. Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen. The specimen was inspected and appeared to be completely intact. It was sent for permanent section. The bladder neck mucosa was then everted by using 4-0 chromic sutures. Inspection at the prostatic bed revealed no bleeding vessels. The sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck. Once the posterior sutures had been placed, the Foley was placed into the urethra and into the bladder neck. A 20-French Foley Catheter was used. The anterior sutures were then placed. The Foley was then inflated. The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly. Mild traction of the Foley catheter was placed to assure the anastomosis was tight. Two #19-French Blake drains were placed in the perivesical spaces. These were anchored to the skin by using 2-0 silk sutures. The instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed. The fascia was closed in running fashion using #1 PDS. Subcutaneous tissue was closed by using 2-0 Vicryl suture. Skin was approximated by using metallic clips. The patient tolerated the operation well.
## 230 HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids. He also has VACTERL association with hydrocephalus. As an infant, he underwent placement of a right modified central shunt. On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt. On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt. A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization. He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels. Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units. On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation. A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion. The patient then followed conservatively since that time. The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:, After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava. This catheter was then exchanged for a 5-French VS catheter of a distal wire. Apposition of the right pulmonary artery over, which the wedge catheter was advanced. The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle. The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance. Left ventricular pressure was found to be suprasystemic. A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure. Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum. Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium. There was a disappearance of a mild waist prior to spontaneous tear of the balloon. The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve. A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste. Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle. Further attempts to cross tricuspid valve were thus abandoned. Attention was then directed to a Fontan fenestration. A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg. With less than 10% fall in calculated cardiac index. The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm. A 7-French flexor sheath was again advanced cross the fenestration. A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium. Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk. Once the stable device configuration was confirmed, device was released from the delivery catheter. Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to systemic arterial desaturation. There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow. The right pulmonary veins were fully saturated. Left pulmonary veins were not entered. There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration. Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery. Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg. Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta. Phasic ascending and descending aortic pressures were similar and normal. The calculated systemic flow was normal. Pulmonary flow was reduced to the QT-QS ratio of 0.7621. Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle. The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries. There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle. Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis. There was symmetric contrast flow to both pulmonary arteries. A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration. There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow. The branch pulmonaries appeared mildly hypoplastic. Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility. Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava. Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery. There was an increase in the systemic arterial pressures. Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%. The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921. Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow. An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries. A small degree of contrast returned to the heart.,INITIAL DIAGNOSES: ,1. Pulmonary atresia.,2. VACTERL association.,3. Persistent sinusoidal right ventricle to the coronary communications.,4. Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Systemic to pulmonary shunts.,2. Right bidirectional Glenn shunt.,3. Revision of the central shunt.,4. Ligation and division of patent ductus arteriosus.,5. Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6. Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES: ,1. Favorable Fontan hemodynamics.,2. Hypertensive right ventricle.,3. Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4. Patent Fontan fenestration.,CURRENT INTERVENTION: ,1. Balloon dilation tricuspid valve attempted and failed.,2. Occlusion of a Fontan fenestration.,MANAGEMENT: ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair. Further cardiologic care will be directed by Dr. X.
## 231 PREOPERATIVE DIAGNOSIS: , Ovarian cancer.,POSTOPERATIVE DIAGNOSIS:, Ovarian cancer.,OPERATION PERFORMED:, Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance.,DETAILED OPERATIVE NOTE:, The patient was placed on the operating table and placed under LMA general anesthesia in preparation for insertion of a Port-A-Catheter. The chest was prepped and draped in the routine fashion for insertion of a Port-A-Catheter. The left subclavian vein was punctured with a single stick and a guidewire threaded through the needle into the superior vena cava under fluoroscopic guidance. The needle was removed. An incision was made over the guidewire for entrance of the dilator with sheath. A second counter incision was made transversally on the chest wall about an inch and half below the puncture site with a #15 blade. Hemostasis was effective to electrocautery, and a pocket was fashioned subcutaneously for positioning of the reservoir. The Port-A-Catheter reservoir tubing was attached to the reservoir in the routine fashion. The reservoir was placed in the pocket and sutured to the anterior chest wall muscle with three interrupted 4-0 Prolene sutures for stability. Next, a catheter passer was passed from the pocket exiting through the skin at the puncture site, previously placed for the guidewire, and the Port-A-Catheter was pulled from the reservoir exiting on the skin. It was placed on the chest, measured, and cut to the appropriate length. This having been done, the dilator with sheath attached was passed over the guidewire into the superior vena cava under fluoroscopic guidance. The guidewire and dilator were removed, and the Port-A-Catheter was threaded through the sheath into the superior vena cava, and the sheath removed under fluoroscopic guidance. Fluoroscopy revealed the Port-A-Catheter to be in excellent position. The Port-A-Catheter was accessed with a butterfly 90-degree needle percutaneously that drew blood well and flushed easily. It was flushed with heparinized saline connected in cath. This having been done, the puncture site was closed with a circumferential subcutaneous 3-0 Vicryl suture, and the skin was closed with a percutaneous circumferential subcuticular suture. This having been done, attention was applied to the reservoir incision. It was closed with two layers of continuous 3-0 Vicryl suture, and the skin was closed with a continuous 3-0 Monocryl subcuticular stitch. A dry sterile dressing was applied, and the patient having tolerated the procedure was transferred to the recovery room for postoperative care.
## 232 PREOPERATIVE DIAGNOSIS: ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,OPERATION: , Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,ANESTHESIA: , Endotracheal.,ESTIMATED BLOOD LOSS: , 250 mL,REPLACEMENTS: ,3 units of packed cells.,DRAINS:, None.,COMPLICATIONS: , None.,PROCEDURE: ,With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma. Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery. The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and Allis clamps. The bone flap, which had not been fixed in place was removed. An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool, B1 attached to the Midas Rex instrumentation. Further bone removal was accomplished with Leksell rongeur, and hemostasis controlled with the use of bone wax.,At this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery. It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex. The sylvian fissure was then dissected with the dissection description being dictated by Dr. X.,Following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior. This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation. Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,Attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr. X. With removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission. Self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation. Following removal of additional hematoma, the bed of the hematoma site was lined with Surgicel. Irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard. The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,With this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region. The wound was then closed. It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap. The wound was then closed by approximating the temporalis muscle with 2-0 Vicryl suture, the fascia was closed with 2-0 Vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications.
## 233 TITLE OF PROCEDURE: , Insertion of Port-A-Cath via left subclavian vein using fluoroscopy.,PREOPERATIVE DIAGNOSIS: ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Metastatic renal cell carcinoma.,PROCEDURE IN DETAIL:, This is a 49-year-old gentleman was referred by Dr. A. The patient underwent a left nephrectomy for renal cell carcinoma in 1999 in Philadelphia. He has developed recurrence with metastases to the lung and to bone.,The patient is on dialysis via a right internal jugular PermCath that was placed elsewhere.,In the operating room under monitored anesthesia care with intravenous sedation, the patient was prepped and draped suitably. Lidocaine 1% with epinephrine was used for local anesthesia and the left subclavian vein was punctured at the first pass without difficulty. A J-wire was guided into place under fluoroscopic control. A 7.2-French vortex titanium Port-A-Cath was now anchored in the subcutaneous pocket made just below using 3-0 Prolene. The attached catheter tunneled, cut to the appropriate length and placed through the sheath that was then peeled away. Fluoroscopy showed good catheter disposition in the superior vena cava. The catheter was accessed with a butterfly Huber needle, blood was aspirated easily and the system was then flushed using heparinized saline. The pocket was irrigated using antibiotic saline and closed with absorbable suture. The port was left accessed with the butterfly needle after dressings were applied and the patient is to report to Dr. A's office later today for the commencement of chemotherapy. There were no complications.
## 234 PROCEDURES PERFORMED,1. Insertion of subclavian dual-port Port-A-Cath.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the chest was prepped and draped in a standard surgical fashion. A #18-gauge spinal needle was used to aspirate blood from the subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire. The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next a #15-blade scalpel was used to make an incision in the skin. Dissection was carried down to the level of the pectoralis muscle. A pocket was created. A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene. Both ports were flushed. The distal tip was pulled through to the wire exit site with a Kelly clamp. It was cut to the appropriate length. Next a dilator and sheath were threaded over the J wire. The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn. Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty. The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. The wire access site was closed with a 4-0 Monocryl. The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition
## 235 PREOPERATIVE DIAGNOSES: ,1. Bilateral breast carcinoma.,2. Chemotherapy required.,POSTOPERATIVE DIAGNOSES:,1. Bilateral breast carcinoma.,2. Chemotherapy required.,OPERATION: , Right subclavian Port-a-Cath insertion.,FINDINGS AND PROCEDURE: ,With the patient under satisfactory general orotracheal anesthesia and in the supine position, the right upper anterior chest, neck, and arm were prepared with Betadine in the usual fashion. The skin, subcutaneous tissue, and fascia of the pectoralis major muscle medially beneath the inferior third of the right clavicle was infiltrated with 0.5% Marcaine with epinephrine. An incision transverse, parallel, and inferior to the middle third of the right clavicle was performed. A subcutaneous pocket on the surface of the pectoralis major muscle was created. The muscular fascia was also infiltrated with 0.5% Marcaine with epinephrine. With the patient in the Trendelenburg position, utilizing the provided introducer needle, the right subclavian vein was cannulated. A guidewire was passed without difficulty and the needle was removed. Fluoroscopy confirmed satisfactory position of the guidewire in the right atrium. A dilator and sheath was passed over the guidewire. The guidewire and dilator were removed and a provided catheter was inserted through the sheath and the sheath was carefully withdrawn. Fluoroscopy again confirmed satisfactory position of the catheter and the catheter under fluoroscopic guidance was retracted into the superior vena cava. The catheter had been preflushed with dilute heparin solution (100 units/mL). The port, which had been preflushed with saline, was attached to the catheter at approximately 13 cm level. The locking cap had been placed on the catheter. The port was connected to the catheter and the locking cap was secured. The port was again flushed with dilute heparin solution and placed within the subcutaneous pocket. Fluoroscopy again confirmed satisfactory position. A hard copy of the fluoroscopy was obtained. The catheter and port were secured to the pectoralis fascia in four locations with 2-0 Prolene suture. Site was irrigated with saline. Hemostasis was verified. The subcutaneous tissue was approximated with interrupted 2-0 Vicryl suture. The subcutaneous and dermis were closed with a running subcuticular 3-0 Vicryl suture. A 0.25-inch Steri-Strips were applied. The provided needle and butterfly attachment was flushed with saline, passed through the skin into the port, and then flushed again with dilute heparin solution thus confirmed satisfactory. The site was dressed with Tegaderm type dressing and the needle catheters were covered with 4x4's and paper tape. Estimated blood loss was less than 15 mL. The patient tolerated the procedure well and left the operating room in good condition.
## 236 PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:, Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:, General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding. Digital exam reveals bright red blood on the finger. He is for exam under anesthesia and control of hemorrhage at this time.,FINDINGS: , There was an ulcer where most of the polypoid lesion had been excised before. In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa. There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture. No other obvious bleeding was seen.,TECHNIQUE: , The patient was taken to the operating room and placed on the operative table in supine position. After adequate general anesthesia was induced, the patient was then placed in modified prone position. His buttocks were taped, prepped and draped in a sterile fashion. The anterior rectal wall was exposed using a Parks anal retractor. The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery. There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well. This was controlled with a 3-0 Monocryl figure-of-eight suture. At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition.
## 237 PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE: ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________ was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS: ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine under general anesthesia. First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep. Sterile dressing was placed. The laryngeal monitoring was noted to be working fine. Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level. The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found. Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments. The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed. No bleeding was seen. There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature. After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature. After this was completed, no bleeding was seen. The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally. Procedure was then terminated at that time.
## 238 PREOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,POSTOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,OPERATIVE PROCEDURE:,1. Placement of a Port-A-Cath.,2. Fluoroscopic guidance.,ANESTHESIA:, General LMA.,ESTIMATED BLOOD LOSS:, Minimum.,IV FLUIDS: , Per anesthesia.,RECURRENT COMPLICATIONS: , None.,FINDINGS: , Good port placement on C-arm.,INDICATIONS AND PROCEDURE IN DETAIL: , This is a 55-year-old female who presents with anal cancer, who is beginning chemoradiation and needs IV access for chemotherapy. Risks and benefits of the procedure explained, the patient appeared to understand, and agreed to proceed. The patient was taken to the operating room, placed in supine position. General LMA anesthesia was administered. She is prepped and draped in the usual sterile fashion. She was placed in the Trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire. Fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava. The incision was then made around the guide wire, taken to the subcutaneous tissues with electric Bovie cautery. A pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements. The 2-0 Vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a Port catheter being placed into the sheath introducer. Fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3-0 Vicryl followed by running 4-0 Vicryl subcuticular stitch. Heparin flush was used to flush the port. Steri-Strips were applied and the patient was awakened and extubated in the OR taken to the PACU in good condition. All counts were reported as correct and I was present for the entire procedure.
## 239 PREOPERATIVE DIAGNOSES,1. Metastatic carcinoma of the bladder.,2. Bowel obstruction.,POSTOPERATIVE DIAGNOSES,1. Metastatic carcinoma of the bladder.,2. Bowel obstruction.,PROCEDURE: , Port insertion through the right subclavian vein percutaneously under radiological guidance.,PROCEDURE DETAIL: ,The patient was electively taken to the operating room after obtaining an informed consent. A time-out process was followed. Antibiotics were given. Then, the patient's right deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated. The right subclavian vein was percutaneously cannulated without any difficulty. Then using the Seldinger technique, the catheter part of the port, which was a single-lumen port, was passed through the introducer under x-ray guidance and placed in the junction of the superior vena cava and the right atrium.,A pocket had been fashioned and a single-lumen drum of the port was connected to the catheter, which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl. Then, the fascia was closed using subcuticular suture of Monocryl. The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed. A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away.,The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. A chest x-ray was performed that showed that there were no complications of procedure and that the catheter was in right place.
## 240 PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Minimal.,PROCEDURE IN DETAIL: ,Patient was prepped and draped in sterile fashion. The left subclavian vein was cannulated with a wire. Fluoroscopic confirmation of the wire in appropriate position was performed. Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed. Once the catheter was advanced through the sheath, the sheath was peeled away. Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed. No hemorrhage was identified. The port was in appropriate position with fluoroscopic confirmation. The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch. Dressed with Steri-Strips and 4 x 4's. Port was checked. Had good blood return, flushed readily with heparinized saline.
## 241 TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. She was started on Dostinex with increasing dosages. The most recent MRI demonstrated an increased growth with hemorrhage. This was then discontinued. Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion. All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL: ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine. The fluoroscope was then positioned. The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus. Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed. It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent. Once this was ensured and completed and hemostasis obtained, the wound was irrigated. There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate. The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure. All sponge and needle counts were correct. The patient was extubated and transported to the recovery room in stable condition. Blood loss was minimal.
## 242 PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE: ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA: ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None. Post-fixation x-rays, nonalignment, no new changes. Post-fixation neurologic examination normal.,CLINICAL HISTORY: ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy. She was referred to me by Dr. X. The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate. Surgery had gone well, and the patient has done well in the last 2 days. She is neurologically improved and is moving all four extremities. No airway issues. It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller. She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest. The patient had this procedure done at the bedside, in the SICU room #1. I used a combination of some morphine 1 mg and Versed 2 mg for this procedure. I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:, The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine. A large PMT crown was brought in and fixed to the skull with pins under local anesthetic. Excellent fixation achieved. It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck. The vest was brought in from the front as well and connected. Head was tilted appropriately, slightly extended, and in the midline. All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout. X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days. Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery. She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.
## 243 PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound. Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right. Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L. The patient tolerated the procedure well. Portable x-ray is pending.
## 244 PREOPERATIVE DIAGNOSIS:, Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:, Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE: ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The right upper extremity was then prepped and draped in standard surgical fashion. A small incision was made at the tip of the olecranon. Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal. This was changed for a 0.79 K-wire. This was driven up to the fracture site. The fracture was manually reduced and then the K-wire passed through the distal segment. This demonstrated adequate fixation and reduction of both bones. The pin was then cut short. The fracture site and pin site was infiltrated with 0.25% Marcaine. The incision was closed using 4-0 Monocryl. The wounds were cleaned and dried. Dressed with Xeroform, 4 x 4. The patient was then placed in a well-moulded long-arm cast. He tolerated the procedure well. He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal. X-rays of the right forearm will be taken. The patient may need additional mobilization time. Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months. Intraoperative findings were relayed to the parents. All questions were answered.
## 245 PREOPERATIVE DIAGNOSIS:, Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:, 10 cc of 0.5% Marcaine plain with TIVA.,HISTORY: ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint. The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment. The patient has been NPO since mid night. Consent is signed and in the chart. No known drug allergies.,Details Of Procedure: An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach. Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia. The foot was then prepped and draped in the usual sterile orthopedic fashion. An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge. Attention was then directed to the plantar medial aspect of the left heel. An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated. A #15 blade was then used to transect the medial and central bands of the plantar fascia. Care was taken to preserve the lateral fibroids. The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted. The air was then flushed with copious amounts of sterile saline. The skin incision was then closed with #3-0 nylon in simple interrupted fashion. Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot. Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case. The patient is to be nonweightbearing on the left lower extremity with crutches. The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d. The patient is to follow-up with Dr. X as directed.
## 246 PREOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,PROCEDURE:,1. Conscious sedation.,2. Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:, None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:, After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning.
## 247 PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:, Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma. He did not return for followup or radiotherapy as instructed, and the tumor has regrown. For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible. The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him. Many risks including CSF leak and blindness were discussed in detail. After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE: ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position. Care was taken to pad all pressure points appropriately. The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space. Clear and colorless CSF issued forth. A catheter was inserted to a distance of 40 cm, and the needle was removed. The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas. Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor. This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed. He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder. Care was taken to pad all pressure points appropriately. The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection. The metallic arm was then connected to the table for the use of the endoscope. The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use. Hemostasis was obtained. The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril. The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium. Needle Bovie electrocautery was used to clear mucosa away from the ostium. The perpendicular plate of the ethmoid had already been separated from the sphenoid. I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this. I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of. The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized. Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma. A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor. I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free. The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right. There appeared to be cavernous sinus invasion on the left. It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter. A large amount of this was removed. There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor. While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus. In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression. Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained. I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction. I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air. Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation. The middle turbinates were then restored to their anatomic position. There was no significant intranasal bleeding, and for this reason, an open nasal packing was required. Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition. The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.
## 248 S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old. He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face. He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet. He has redness of the right toes 2, 3 and 4. Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1. Plantar fasciitis.,
## 249 PREOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1. External fixation of left pilon fracture.,2. Closed reduction of left great toe, T1 fracture.,ANESTHESIA: ,General.,BLOOD LOSS: ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:, None.,INDICATION FOR OPERATION: ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009. The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time. The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness. She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome. Risks and benefits of procedure were discussed in detail with the patient and her husband. All questions were answered, and consent was obtained. The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1. There was a comminuted distal tibia fracture with a fibular shaft fracture. Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2. The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement. As the reduction was stable with buddy taping, no pinning was performed.,3. Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL: ,The patient was identified in the preoperative holding area. The left leg was identified and marked at the surgical site of the patient. She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team. She received Ancef for antibiotic prophylaxis. A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics. When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion. At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site. A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able. When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture. Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive. X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture. At this point, the pins were cut short and capped to protect the sharp ends. The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition. Please note there was no break in sterile technique throughout the case.,PLAN: ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication. She will maintain her buddy taping in regards to her great toe fracture.
## 250 PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:, Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room. A time-out process was followed. Antibiotics were given and then the patient was prepped and draped in the usual fashion. It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating. An elliptical excision of all infected tissues down to the coccyx was performed. Hemostasis was achieved with a cautery. The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,The patient was sent to recovery room in satisfactory condition. Estimated blood loss was minimal. The patient tolerated the procedure well.
## 251 PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS: ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL: ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluoroscopic views. Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. Risks and benefits of surgery were discussed. Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A small bump was placed underneath her right buttock. The right upper thigh was then prepped and draped in standard surgical fashion. The upper aspect of the incision was reincised. The dissection was carried down to the crew, which was easily found. A guidewire was placed inside the screw with subsequent removal of the previous screw. The previous screw measured 65 mm. A 60 mm screw was then placed under direct visualization with fluoroscopy. The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion. The guidewire was removed. The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat. The skin was closed with 4-0 Monocryl. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape. The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery. She should continue toe touch weightbearing on her leg. The wound may be wet in approximately 5 days. The patient should follow up in clinic in about 10 days. The patient is given Vicodin for pain. Intraoperative findings were relayed to the mother.
## 252 PREOPERATIVE DIAGNOSIS: ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL: ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.
## 253 PROCEDURE CODES: 64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA: MAC.,COMPLICATIONS: None.,DESCRIPTION OF TECHNIQUE: Informed consent was obtained from the patient's mom. The patient was brought to minor procedures and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation. Approximately 4 mL of 5% phenol was injected in this location bilaterally. Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. After injections were performed, bilateral short leg fiberglass casts were applied. The patient tolerated the procedure well and no complications were encountered.
## 254 PROCEDURES PERFORMED:, Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:, Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother. The patient was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation. Approximately 7 mL was injected on the right side and 5 mL on the left side. At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol. The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation. Approximately 5 mL of 5% phenol was injected in this location. Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation. Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.
## 255 PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.
## 256 PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:, Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient. She was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse. Approximately 6 mL of 5% phenol was injected in this location. At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles. Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.
## 257 PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE: ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA: ,Topical.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,The patient was identified. The operative eye was treated with tetracaine 1% topically in the preoperative holding area. The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye. The lashes were tapped using Steri-Strips to prevent blinking. A lid speculum was placed to prevent lid closure. Anesthesia was verified. Then, a 3.5-mm groove was created with a diamond blade temporarily. This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane. A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat. A paracentesis was made. A round capsulorrhexis was performed. The anterior capsular flap was removed. Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique. The irrigating-aspirating machine was used to clear residual cortex. The Provisc was instilled. An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified. The viscoelastic was removed. Intraocular lens remained well centered. The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal. The anterior chamber remained deep, and there was no wound leak. The patient tolerated the procedure well. The eye was dressed with Maxitrol ointment. A tight patch and Fox shield were placed. The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.
## 258 PROCEDURE PERFORMED:, PICC line insertion.,DESCRIPTION OF PROCEDURE:, The patient was identified by myself on presentation to the angiography suite. His right arm was prepped and draped in sterile fashion from the antecubital fossa up. Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein. A guidewire was then threaded through the vein and advanced without difficulty. An introducer was then placed over the guidewire. We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram. What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein. It was very tortuous area. We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that. Decision was made at that point then to just do a midline catheter. The catheter was cut to 20 cm, then we inserted back to the introducer. The introducer was removed. The catheter was secured by two #3-0 silk sutures. Appropriate imaging was then taken. Sterile dressing was applied. The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor. We may make another attempt in the near future using a different approach.,
## 259 TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child. He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract. He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,PREOP DIAGNOSIS:,1. History of open globe to the right eye.,2. History of retinal detachment status post repair in the right eye.,3. Silicone oil in anterior chamber.,4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,POSTOP DIAGNOSIS:,1. History of open globe to the right eye.,2. History of retinal detachment status post repair in the right eye.,3. Silicone oil in anterior chamber.,4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,ANESTHESIA: , General.,PROS DEV IMPLANT: , ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,NARRATIVE: , Informed consent was obtained. All questions were answered. The patient was brought to preoperative holding area where the operative right eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced by the anesthesia service. A time-out was called to confirm the procedure and operative eye. The right operative eye was disinfected and draped in a standard fashion for eye surgery. A lid speculum was placed. The vitreoretinal team placed the infusion cannula after performing a peritomy. At this point in the case, the patient was turned over to the cornea service with Mrs. Jun. A paracentesis was made at the approximately 3 o'clock position. Healon was placed into the anterior chamber. The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis. This incision was then shelved anteriorly and used to enter the anterior chamber. The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome. Hydrodissection was performed. The lens nucleus was removed using phacoemulsification and irrigation and aspiration. Lens cortex also was removed using irrigation and aspiration. Viscoelastic was placed to inflate the capsular remnant. The diamond knife was used to enlarge the phaco incision. Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty. The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed. The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber. This was done without difficulty. The anterior chamber was secured and watertight at the end of the procedure. Intraocular pressure was satisfactory. The patient tolerated the procedure well and then was turned over to the retina service in good condition. They will dictate a separate note.
## 260 PREOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:, Alcon, model SN60WF, power of 22.5 diopters., ,PHACOEMULSIFICATION TIME:, 1 minute 41 seconds at 44.4% power., ,INDICATIONS FOR PROCEDURE: , This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40. The patient complains of difficulties with glare in performing activities of daily living.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery. All questions from the patient were answered after the surgical procedure was explained in detail. The risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc. Alternative of the procedure is to do nothing or seek a second opinion. Informed consent for this procedure was obtained from the patient.,OPERATIVE TECHNIQUE: , The patient was brought to the holding area. Previously, an intravenous infusion was begun at a keep vein open rate. After adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye. A total of 10 mL mixture with a 70/30 mixture of 2% Xylocaine without epinephrine and 0.75% bupivacaine without epinephrine. An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area. Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted. Vital sign monitors were detached from the patient. The patient was moved to the operative suite and the same monitors were reattached. The periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery. The speculum was set into place and the operative microscope was brought over the eye. The eye was examined. Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea. Then a pocket incision was created without entering the anterior chamber of the eye. Two peripheral paracentesis ports were created on each side of the initial incision site. Viscoelastic was used to deepen the anterior chamber of the eye. A 2.65 mm keratome was then used to complete the corneal valve incision. A cystitome was bent and created using a tuberculin syringe needle. It was placed in the anterior chamber of the eye. A continuous curvilinear capsulorrhexis was begun. It was completed using O'Gawa Utrata forceps. A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus. The lens nucleus was noted to be freely mobile in the bag.,The phacoemulsification tip was placed into the anterior chamber of the eye. The lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique. All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports. The posterior capsule remained intact throughout the entire procedure. Provisc was used to deepen the anterior chamber of the eye. A crescent blade was used to expand the internal aspect of the wound. The lens was taken from its container and inspected. No defects were found. The lens power selected was compared with the surgery worksheet from Dr. X's office. The lens was placed in an inserter under Provisc. It was placed through the wound, into the capsular bag and extruded gently from the inserter. It was noted to be adequately centered in the capsular bag using a Sinskey hook. The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique. The eye was noted to be inflated without overinflation. The wounds were tested for leaks, none were found. Five drops dilute Betadine solution was placed over the eye. The eye was irrigated. The speculum was removed. The drapes were removed. The periocular area was cleaned and dried. Maxitrol ophthalmic ointment was placed into the interpalpebral space. A semi-pressure patch and shield was placed over the eye. The patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with Dr. X tomorrow morning in the office.
## 261 PROCEDURE: , Phacoemulsification with posterior chamber intraocular lens insertion.,INTRAOCULAR LENS: , Allergan Medical Optics model S140MB XXX diopter chamber lens.,PHACO TIME:, Not known.,ANESTHESIA: , Retrobulbar block with local minimal anesthesia care.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS:, None.,DESCRIPTION OF PROCEDURE: , While the patient was in the holding area, the operative eye was dilated with four sets of drops. The drops consisted of Cyclogyl 1%, Acular, and Neo-Synephrine 2.5 %. Additionally, a peripheral IV was established by the anesthesia team. Once the eye was dilated, the patient was wheeled to the operating suite.,Inside the operating suite, central monitoring lines were established. Through the peripheral IV, the patient received intravenous sedation consisting of Propofol and once somnolent from this, retrobulbar block was administered consisting of 2 cc's of 2% Xylocaine plain with 150 units of Wydase. The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained. Digital pressure was applied for approximately five minutes.,The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery. A Betadine prep was carried out of the face, lids, and eye. During the draping process, care was taken to isolate the lashes. A wire lid speculum was inserted to maintain patency of the lids. With benefit of the operating microscope, a diamond blade was used to place a groove temporally. A paracentesis wound was also placed temporally using the same blade. Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2.8 mm. diamond keratome was used to enter the anterior chamber through the previously placed groove. The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty. The capsular remnant was withdrawn from the eye using long angled McPherson forceps. Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed. The lens was noted to rotate freely within the capsular bag. The phaco instrument was then inserted into the eye using the Kelman tip. The lens nucleus was grooved and broken into two halves. One of the halves was in turn broken into quarters. Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification. Attention was then turned toward the remaining half of the nucleus and this, in turn, was removed as well, with the splitting maneuver. Once the nucleus had been removed from the eye, the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections. Once the cortical material had been completely removed, a diamond dusted cannula was inserted into the eye and the posterior capsule was polished. Viscoelastic was again instilled into the capsular bag as well as the anterior chamber. The wound was enlarged slightly using the diamond keratome. The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps. Once inside the eye, the lens was unfolded into the capsular bag in a single maneuver. It was noted to be centered nicely. The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine.,Next, Miostat was instilled into the operative eye and the wound was checked for water tightness. It was found to be such. After removing the drapes and speculum, TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye.,The patient tolerated the procedure extremely well and was taken to the recovery area in good condition. The patient is scheduled to be seen in follow-up in the office tomorrow, but should any complications arise this evening, the patient is to contact me immediately.
## 262 PREOPERATIVE DIAGNOSIS:, Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:, Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:, TIVA/local.,HISTORY:, This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity. The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed. The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis. The patient desires to attempt a surgical correction. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X. The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist. Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block. The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm. There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally. The toe was 2.5 times to the normal size. There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected. The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively. X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx. A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx. The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact. Next, the distal phalanx was disarticulated at the interphalangeal joint and removed. The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology. Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected. Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx. This bone was also sent off for culture and was labeled proximal margin. Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected. The flexor tendon distally was gray discolored and was not viable. A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally. None was found. No purulent drainage or abscess was found. The proximal margin of the surgical site tissue was viable and healthy. There was no malodor. Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology. Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension. The plantar flap was viable and was debulked with Metzenbaum scissors. The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures. Iris scissors were used to modify and remodel the plantar flap. An excellent cosmetic result was achieved. No tourniquet was used in this case. The patient tolerated the above anesthesia and surgery without apparent complications. A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban. The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot. He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications. Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches. He will elevate his right foot and rest the foot, keep it clean and dry. He is to follow up with Dr. X on Monday or Tuesday of next week.
## 263 PREOPERATIVE DIAGNOSIS:, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,OPERATION PERFORMED: , Phacoemulsification with IOL, right eye.,ANESTHESIA:, Topical with MAC.,COMPLICATIONS,: None.,ESTIMATED BLOOD LOSS: , None.,PROCEDURE IN DETAIL: After appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat. A 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata. BSS on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I&A. Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I&A, which then removed all remaining cortex as well as viscoelastic material. BSS on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed. Under microscope, the anterior chamber being soft and well formed. Pred Forte, Vigamox, and Iopidine were placed in the eye. A shield was placed over the eye. The patient was followed to recovery where he was noted to be in good condition.
## 264 OPERATION PERFORMED:, Phacoemulsification of cataract and posterior chamber lens implant, right eye., ,ANESTHESIA:, Retrobulbar nerve block, right eye, ,DESCRIPTION OF OPERATION: ,The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine and a Honan balloon. Once anesthesia was achieved, the right eye was prepped with Betadine, rinsed with saline, and draped in a sterile fashion. A lid speculum was placed and 4-0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe. A fornix-based conjunctival flap was prepared superiorly from 10 to 12 o'clock and episcleral vessels were cauterized using a wet-field. A surgical groove was applied with a 69 Beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o'clock position. A lamellar dissection was carried anteriorly to clear cornea using a crescent knife. A stab incision was applied with a Superblade at the 2 o'clock position at the limbus. The chamber was also entered through the lamellar groove using a 3-mm keratome in a beveled fashion. Viscoat was injected into the chamber and an anterior capsulorrhexis performed. Hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber. A deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side-port incision. A second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants. Each quadrant was emulsified under burst power within the capsular bag. The epinuclear bowl was manipulated with vacuum, flipped into the iris plane, and emulsified under pulse power. I&A was used to aspirate cortex from the capsular bag. A scratcher was used to polish the capsule, and Viscoat was injected inflating the capsular bag and chamber. The wound was enlarged with a shortcut blade to 5.5 mm. The intraocular lens was examined, found to be adequate, irrigated with balanced salt, and inserted into the capsular bag. The lens centralized nicely and Viscoat was removed using the I&A. Balanced salt was injected through the side-port incision. The wound was tested, found to be secure, and a single 10-0 nylon suture was applied to the wound with the knot buried within the sclera. The conjunctiva was pulled over the suture, and Ancef 50 mg and Decadron 4 mg were injected sub-Tenon in the inferonasal and inferotemporal quadrants. Maxitrol ointment was applied topically followed by an eye pad and shield. The patient tolerated the procedure and was taken from the operating room in good condition.
## 265 PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE:, Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:, None,SPECIMENS:, None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye. The patient had the risks and benefits of surgery discussed. After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed. Following this, the patient was sterilely prepped and draped in the usual fashion. After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis. Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision. Following this, the cystotome was used to make a continuous tear-type capsulotomy. After this, BSS was used to hydrodissect and hydrodelineate the lens. The phacoemulsification unit was used to remove the cataract. The I&A unit was used to remove the residual cortical material. Following this, Provisc was used to inflate the bag. The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed. Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight. The lid speculum was removed. Acular and Vigamox drops were placed. The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.
## 266 PREOPERATIVE DIAGNOSIS: ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS: ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE: ,Right eye was prepped and draped in the normal sterile fashion. Lid speculum placed in his right eye. Paracentesis made supratemporally. Viscoat injected into the anterior chamber. A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally. This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed. Nuclear material removed via phacoemulsification. Residual cortex removed via irrigation and aspiration. The posterior capsule was clear and intact. Capsular bag was then filled with Provisc solution. The wound was enlarged to 3.5 mm with the keratoma. The lens was folded in place into the capsular bag. Residual Provisc was irrigated from the eye. The wound was secured with one 10-0 nylon suture. The lid speculum was removed. One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment. He had a patch placed on it. The patient was transported to the recovery room in stable condition.
## 267 PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE: ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops. Topical anesthetic drops were applied to the eye just prior to entering the operating room. The eye was then prepped with a 5% Betadine solution injected in the usual sterile fashion. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. Lidocaine 1% preservative-free, 0.1 cc, was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber. A 2.8-mm keratome was used to create a self-sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap. The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula. Phacoemulsification in a quartering and cracking technique was used to remove the nucleus, and then the residual cortex was removed with the irrigation and aspiration unit. Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit. The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size to accommodate the intraocular lens insertion using an additional keratome blade.,The lens was folded, inserted into the capsular bag and then unfolded. The trailing haptic was tucked underneath the anterior capsular rim. The lens was shown to center very well. The viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction. The wound was shown to be watertight. Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied, and a Fox shield taped firmly in place over the eye.,The patient tolerated the procedure well and left the operating room in good condition.
## 268 PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,TITLE OF OPERATION: ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where retrobulbar anesthesia was induced. The patient was then prepped and draped using standard procedure. A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12. The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome. The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed. The phacoemulsification was then instilled in the eye and a linear incision made in the lens. The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip. The remaining cortex was removed with an I&A. The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome. The folding posterior chamber lens was then inserted in the capsular bag and rotated into position. The remaining viscoelastic was removed from the eye with the I&A. The wound was checked for watertightness and found to be watertight. Tobramycin drops were instilled in the eye and a shield placed over it. The patient tolerated the procedure well.
## 269 PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, right eye.,PROCEDURE PERFORMED: ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,COMPLICATIONS:, None.,PROCEDURE: , Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling. The patient understood the risks clearly and wished to proceed.,The patient was brought into the operating suite after being given dilating drops. Topical 4% lidocaine drops were used. The patient was prepped and draped in the normal sterile fashion. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters. This was exchanged for Viscoat solution. Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus. This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade. Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps. Balanced salt solution was used to hydrodissect the nucleus. Nuclear material was removed via phacoemulsification with divide-and-conquer technique. The residual cortex was removed via irrigation and aspiration. The capsular bag was then filled with Provisc solution. The wound was slightly enlarged. The lens was folded and inserted into the capsular bag.,Residual Provisc solution was irrigated out of the eye. The wound was stromally hydrated and noted to be completely self-sealing.,At the end of the case, the posterior capsule was intact. The lens was well centered in the capsular bag. The anterior chamber was deep. The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly. Maxitrol ointment was placed into the eye. The eye was patched with a shield.,The patient was transported to the recovery room in stable condition to follow up the following morning.
## 270 PREOPERATIVE DIAGNOSIS:, Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:, Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:, This patient has been experiencing difficulty with eyesight regarding activities of daily living. There has been a progressive and gradual decline in the visual acuity. The cataract was believed related to her decline in vision. The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail. The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery. The possibility of needing intraocular lens exchange or incorrect lens power was discussed. Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed. It was explained that some or all of these complications might arise at the time of or months to years after surgery. The patient had a good understanding of the risks with the proposed, elective eye surgery. The patient accepted these risks and elected to proceed with cataract surgery. All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. The pupil was dilated per protocol. The patient was taken to the operating room and placed in the supine position. After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage. No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion. An eyelid speculum was used to separate the eyelids. A crescent blade was used to make a clear corneal temporally located incision. A 1-mm Dual-Bevel blade was used to make a paracentesis site. The anterior chamber was filled with viscoelastic (Viscoat). The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision. A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision. A 25-gauge pre-bent cystotome used to begin a capsulorrhexis. The capsulorrhexis was completed with the Utrata forceps. A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted. The lens was able to be freely rotated within the capsular bag. Divide-and-conquer ultrasound was used for phacoemulsification. After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment. Each of the four nuclear quadrants was phacoemulsified. Aspiration was used to remove all remaining cortex. Viscoelastic was used to re-inflate the capsular bag. An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag. The trailing haptic was placed with the Sinskey hook. The lens was made well centered and stable. Viscoelastic was aspirated. BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure. A Weck-Cel sponge was used to check both incision sites for leaks and none were identified. The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens. The eyelid speculum was removed and the patient was cleaned free of Betadine. Vigamox and Econopred drops were applied. A soft eye patch followed by a firm eye shield was taped over the operative eye. The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed. All questions were answered. The discharge instructions were also reviewed with the patient by the discharging nurse. The patient was comfortable and was discharged with followup in 24 hours. Complications none.
## 271 PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where tetracaine drops were instilled in the eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus. This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber. The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc. A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps. The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco. This was aided by cracking the lens nucleus with McPherson forceps. The remaining cortex was removed from the eye with the I&A. The capsular bag was then polished with the I&A on capsular bag. The bag was inflated using viscoelastic and then the wound extended slightly with a keratome. A folding posterior chamber lens was inserted and rotated into position using McPherson forceps. The I&A was then placed in the eye again and the remaining viscoelastic removed. The wound was checked for watertightness and found to be watertight. TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.
## 272 PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye. She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL: ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart. They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established. MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops. The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia. The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome. A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome. The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves. Each half was further subdivided with chopping and removed with phacoemulsification. The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece. The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty. The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS. The corneal wounds were hydrated and verified to be water-tight. Antibiotic ointment was placed, followed by a patch and shield. The patient was transported to the PACU in good/stable condition. There were no complications. Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.
## 273 PREOPERATIVE DIAGNOSIS:, Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO Model SI40 NB, power *** diopters.,INDICATIONS FOR SURGERY: , This patient has been experiencing difficulty with eyesight regarding activities in their daily life. There has been a progressive and gradual decline in the visual acuity. By examination, this was found to be related to cataracts. The risks, benefits, and alternatives (including observation or spectacles) were discussed in detail. The patient accepted these risks and elected to proceed with cataract surgery. All questions were answered and informed consent was obtained.,Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals, risks, and alternatives involved as well as the postoperative instructions. A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery. To minimize and decrease the chance of bacterial infection, the patient was started on a course of antibiotic drops for two days prior to surgery.,DESCRIPTION OF PROCEDURE: ,The patient was identified and the procedure was verified. The pupil was dilated per protocol. The patient was taken to the operating room and placed in a comfortable supine position. The operative table was placed in Trendelenburg head-up tilt to decrease orbital congestion and posterior vitreous pressure. The patient was prepped and draped in the usual ophthalmic sterile fashion. The lids and periorbita were prepped with full-strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins. The conjunctival cul-de-sac was also prepped in dilute Betadine solution. The fornices were also prepped. The drape was done meticulously to ensure complete eyelash inclusion.,An eyelid speculum was placed to separate the eyelids. A paracentesis site was made. Intracameral preservative-free lidocaine was injected. Amvisc Plus was then used to stabilize the anterior chamber. A 3-mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location. A 25-gauge pre-bent cystotome was used to begin a capsulorrhexis. The capsular flap was removed. A 27-gauge blunt cannula was used for hydrodissection. The lens was able to be freely rotated within the capsular bag. Divide-and-conquer technique was used for phacoemulsification. After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment. Each of the four nuclear quadrants was phacoemulsified. Aspiration was used to remove remaining cortex with the I/A handpiece. Viscoelastic was used to re-inflate the capsular bag. The intraocular lens was injected into the capsular bag. The lens was then dialed into position. The lens was well-centered and stable. Viscoelastic was aspirated. BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration. A Weck-Cel sponge was used to check both incision sites for leaks and none were identified. The incision sites remained well approximated and dry with a well-formed anterior chamber and well-centered intraocular lens. The eyelid speculum was removed and the patient was cleaned free of Betadine. Zymar and Pred Forte drops were applied. A firm eye shield was taped over the operative eye. The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed. All questions were answered. The discharge instructions were also reviewed with the patient by the discharging nurse. The patient was comfortable and was discharged with followup in 24 hours.
## 274 DIAGNOSIS:, Nuclear sclerotic and cortical cataract, right eye.,OPERATION:, Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:, The patient was taken to the operating room and placed on the table in the supine position. Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff. Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage. The patient was then prepped and draped in the usual sterile fashion for eye surgery. With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle. With Westcott scissors, a fornix-based conjunctival flap was made. The surgical limbus was identified and hemostasis obtained with wet-field cautery. With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea. A stab incision was made at 2 o'clock with a 15-degree blade. With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber. Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique. Hydrodissection was performed with Balanced Salt Solution. Phacoemulsification was performed in a two-headed nuclear fracture technique. The remaining cortical material was removed with irrigation and aspiration handpiece. The posterior capsule remained intact and vacuumed with minimal suction. The posterior chamber intraocular lens was obtained. It was inspected, irrigated, inserted into the posterior chamber without difficulty. Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound. There was no aqueous leak even with digital pressure. The conjunctiva was pulled back into position with wet-field cautery. A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given. Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture. The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.
## 275 PREOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,POSTOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,TITLE OF PROCEDURES: ,1. Perlane injection for the nasolabial fold.,2. Restylane injection for the glabellar fold.,ANESTHESIA: ,Topical with Lasercaine.,COMPLICATIONS: , None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. This includes risk of bleeding, infection, scarring, need for further procedure, etc. The patient did sign the informed consent form regarding the Perlane and Restylane. She is aware of the potential risk of bruising. The patient has had Cosmederm in the past and had had a minimal response with this. Please note Lasercaine had to be applied 30 minutes prior to the procedure. The excess Lasercaine was removed with a sterile alcohol swab.,Using the linear threading technique, I injected the deep nasolabial fold. We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold. They were carefully massaged into good position at the end of the procedure. She did have some mild erythema noted.,I then used approximately 0.4 mL of the Restylane for injection of the mid glabellar site. She has a resting line of the mid glabella that did not respond with previous Botox injection. Once this was filled, the Restylane was massaged into the proper tissue plane. Cold compressors were applied afterwards. She is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time. Post Restylane and Perlane precautions have been reviewed with the patient as well.
## 276 PREOPERATIVE DIAGNOSES:,1. Nonfunctioning inflatable penile prosthesis.,2. Peyronie's disease.,POSTOPERATIVE DIAGNOSES:,1. Nonfunctioning inflatable penile prosthesis.,2. Peyronie's disease.,PROCEDURE PERFORMED: , Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700.,ANESTHESIA:, General LMA.,SPECIMEN: , Old triple component inflatable penile prosthesis.,PROCEDURE: ,This is a 64-year-old male with prior history of Peyronie's disease and prior placement of a triple component inflatable penile prosthesis, which had worked for years for him, but has stopped working and subsequently has opted for ex-plantation and replacement of inflatable penile prosthesis.,OPERATIVE PROCEDURE: , After informed consent, the patient was brought to the operative suite and placed in the supine position. General endotracheal intubation was performed by the Anesthesia Department and the perineum, scrotum, penis, and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15-minute prep including iodine solution in the urethra. The bladder was subsequently drained with a red Robinson catheter. At that point, the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space. Care was maintained to avoid all bleeding as possible secondary to the fact that we could not use Bovie cautery secondary to the patient's pacemaker and monopolar was only source of hemostasis besides suture. At that point, we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies. Attention was taken then to the tubing, going up to the reservoir in the right lower quadrant. This was dissected out bluntly and sharply with Metzenbaum scissors and monopolar used for hemostasis. At this point, as we tracked this proximally to the area of the rectus muscle, we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis. As we tried to remove the tubing and get to the reservoir, the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery. At that point, this tubing was then tracked down to the pump, which was fairly easily removed from the dartos pouch in the right scrotum. This was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked, first starting on the right side where a corporotomy incision was made at the placement of two #3-0 Prolene stay ties, staying lateral and anterior on the corporal body. The corporal body was opened up and the cylinder was removed from the right side without difficulty. However, we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of Bovie cautery, this was very difficult and was very time consuming, but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures. This was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body. The left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding, which was controlled with monopolar and cautery was used on three different occasions, but just simple small burst under the guidance of anesthesia and there was no ectopy noted. After removal of half of the pump, all the tubing, and both cylinders, these were passed off the table as specimen. Both corporal bodies were then dilated with the Pratt dilators. These were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces. At this point, using the Farlow device, corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally. He had an 18 cm with rear tips in place, which were removed. We decided to go ahead to and use another 18 cm inflatable penile prosthesis. Confident with our size, we then placed rear tips, originally 3 cm rear tips, however, we had difficulty placing the rear tips into the left crest. We felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm. At this point, we went ahead and placed the right cylinder using the Farlow device and the Keith needle, which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally, entered the crest without difficulty. Attention was then taken to the left side with the same thing was carried out, however, we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders. This then forced us to down size to the 1 cm rear tips, which slipping very easily with the Farlow device through the glans penis. There was no crossover and no violation of the tunica albuginea. The rear tips were then placed without difficulty and our corporotomies were closed with #2-0 PDS in a running fashion. ________ starting on the patient's right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants. At that point, the wound was copiously irrigated and the device was inflated multiple times. There was a very good fit and we had a very good result. At that point, the pump was subsequently placed in the dartos pouch, which already has been created and was copiously irrigated with antibiotic solution. This was held in place with a Babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump. Please also note that before placement of our pump, attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis, approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device, which was subsequently placed without difficulty and three simple interrupted sutures of #2-0 Vicryl used to close the defect in the rectus and at that point after placement of our pump, the connection was made between the pump and the reservoir without difficulty. The entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated. After completion of the connection using a straight connector, the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left, but this was able to be ________ with good cosmetic result. At that point, after irrigation again of the space, the area was simply dry and hemostatic. The soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers. The soft tissue and the skin was then reapproximated with staples. Please also note that prior to the skin closure, a Jackson-Pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings, would be left in place for approximately 12 to 20 hours. This was also sutured in place with nylon. Sterile dressing was applied. Light gauze was wrapped around the penis and/or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally. Coban was used then to wrap the penis and at the end of the case the patient was straight catheted, approximately 400 cc of amber-yellow urine. No Foley catheter was used or placed.,The patient was awoken in the operative suite, extubated, and transferred to recovery room in stable condition. He will be admitted overnight to the service of Dr. McDevitt. Cardiology will be asked to consult with Dr. Stomel for a pacer placement and he will be placed on the Telemetry floor and kept on IV antibiotics.
## 277 PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:, Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS: ,This 14-year-old young lady is in the renal failure and in need of dialysis. She had had a previous PD catheter placed, but it became infected and had to be removed. She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection. The fascia was divided and the posterior fascia and peritoneum were identified. A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity. The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision. A PD catheter was then placed into the pelvis over a guidewire. At this point, the peritoneum and posterior fascia was closed around the catheter. The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia. The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site. The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return. The skin was closed with 5-0 subcuticular Monocryl. Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.
## 278 PROCEDURE:, Permacath placement.,INDICATION: , Renal failure.,IMPRESSION: , Status post successful placement of a #4-French Permacath dialysis catheter.,DISCUSSION:, After informed consent was obtained at the request of Dr. Xyz, Permacath placement was performed.,The right neck and anterior chest were sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as a local anesthetic. Using ultrasound guidance, a micropuncture needle was advanced into the internal jugular vein. The wire was then advanced with fluoroscopic guidance. A dilator was placed. An incision was then made at the puncture site for approximately 1 cm in the neck. A 1 cm incision was also made in the anterior chest. The catheter was tunneled subcutaneously from the incision on the anterior chest, out the incision of the neck. Following this, over the wire, the tract into the internal jugular vein was dilated and a peel-away sheath was placed. The catheter was then advanced through the peel-away sheath. The peel-away sheath was removed. The catheter was examined under fluoroscopic imaging and was in satisfactory position. Both ports were aspirated and flushed easily. Following this, the incision on the neck was closed with 2 #3-0 silk sutures. The incision on the anterior chest was also closed 2 #3-0 silk sutures.,The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. The patient was returned to her room in satisfactory condition.
## 279 PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. Informed consent was obtained. On the day of surgery, (s)he received several sets of drops in the XXX eye including 2.5% phenylephrine, 1% Mydriacyl, 1% Cyclogyl, Ocuflox and Acular. (S)he was taken to the operating room and sedated via IV sedation. 2% lidocaine jelly was placed in the XXX eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). The XXX eye was prepped using a 10% Betadine solution. (S)he was covered in sterile drapes leaving only the XXX eye exposed. A Lieberman lid speculum was placed to provide exposure. The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. Then 1% lidocaine was injected through the paracentesis. After the nonpreserved lidocaine was injected, Viscoat was injected through the paracentesis to fill the anterior chamber. The Thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. BSS on a hydrodissection cannula was used to perform gentle hydrodissection. Phacoemulsification was then performed to remove the nucleus. I & A was performed to remove the remaining cortical material. Provisc was injected to fill the capsular bag and anterior chamber. A XXX diopter SN60AT (for Acrysof natural lens) intraocular lens was injected into the capsular bag. The Kuglen hook was used to rotate it into proper position in the capsular bag. I & A was performed to remove the remaining Viscoelastic material from the eye. BSS on the 30-gauge cannula was used to hydrate the wound. The wounds were checked and found to be watertight. The lid speculum and drapes were carefully removed. Several drops of Ocuflox were placed in the XXX eye. The eye was covered with an eye shield. The patient was taken to the recovery area in a good condition. There were no complications.
## 280 PREOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:, Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:, Topical.,COMPLICATIONS:, None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision. They were found to have a visually significant cataract. The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the operating room. A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion. A paracentesis was created at ** o'clock. The anterior chamber was filled with Viscoat. A clear corneal incision was made at ** o'clock with the 3-mm diamond blade. A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps. The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag. The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion. The residual cortex was removed with the irrigation/aspiration handpiece. The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well. The residual Provisc was removed with the irrigation/aspiration handpiece. The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution. The wounds were found to be free from leak. Zymar and Pred Forte were instilled postoperatively. The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications. He will follow up with us in one day.
## 281 PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE: ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS: ,Same as above.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:, No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION: ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection. Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified. Once he was anesthetized, the caudal block was placed and IV antibiotics were given. He was then placed in a supine position and sterilely prepped and draped. Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors. We removed the excessive skin on the shaft skin and on the glans itself. We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic. Electrocautery was used for hemostasis. Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again. IV Toradol was given at the end of procedure. The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.
## 282 <NA>
## 283 PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED: ,1. Pelvic laparotomy.,2. Lysis of pelvic adhesions.,3. Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS: ,There was a transabdominal mass palpable in the lower left quadrant. An ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,PROCEDURE: ,Under general anesthesia, the patient was placed in lithotomy position, prepped and draped. A low transverse incision was made down to and through to the rectus sheath. The rectus sheath was put laterally. The inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 Vicryl sutures. The rectus muscle was then split transversally and the peritoneum was split transversally as well. The left adnexal mass was identified and large bowel was attached to the mass and Dr. Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass. The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament. The infundibulopelvic ligament was isolated, entered via blunt dissection. A #0 Vicryl suture was put into place, doubly clamped with curved Heaney clamps, cut with curved Mayo scissors and #0 Vicryl fixation suture put into place. Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 Vicryl suture was put into place. Pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion. Irrigation was used. Minimal blood loss at the time of surgery was noted. Sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum. Instrument, needle, and sponge counts were called for and found to be correct. The peritoneum was closed with #0 Vicryl continuous running locking suture. The rectus sheath was closed with #0 Vicryl continuous running locking suture. A DonJoy Pain-Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples. Final instrument needle counts were called for and found to be correct. The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition.
## 284 PREOPERATIVE DIAGNOSIS:, Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSIS: , Protein-calorie malnutrition.,PROCEDURE PERFORMED:, Percutaneous endoscopic gastrostomy (PEG) tube.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: ,The patient is a 73-year-old male who was admitted to the hospital with some mentation changes. He was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite. He was placed in the supine position and was given IV sedation by the Anesthesia Department. An EGD was performed from above by Dr. X. The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method. The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization. The needle was removed and a guidewire was inserted through the sheath. The guidewire was grasped from above with a snare by the endoscopist. It was removed completely and the Ponsky PEG tube was secured to the guidewire.,The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall. There was no evidence of bleeding. Photos were taken. The Bolster was placed on the PEG site. A complete dictation for the EGD will be done separately by Dr. X. The patient tolerated the procedure well and was transferred to recovery room in stable condition. He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal.
## 285 TITLE OF OPERATION:,1. Pars plana vitrectomy.,2. Pars plana lensectomy.,3. Exploration of exit wound.,4. Closure of perforating corneal scleral laceration involving uveal tissue.,5. Air-fluid exchange.,6. C3F8 gas.,7. Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall. He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:, General.,SPECIMEN:, None.,IMPLANTS:,1. Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2. Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife. All of their questions were answered. Informed consent was signed. The patient was brought into the operating room. A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye. After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery. A wire lid speculum was used to separate the eyelids of the left eye. A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon. The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried. A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors. Hemostasis was achieved with bipolar cautery. A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant. A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture. The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion. Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule. The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter. The vitreous was trimmed to the vitreous base. A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course. The exit wound was explored. No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps. The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression. No retinal breaks or defects were noted in the periphery. The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees. Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve. The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion. The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures. A 12% concentration of C3F8 gas was flushed through the eye. The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture. All of the sclerotomies were noted to be airtight. The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried. Subconjunctival injections of Ancef and Decadron were delivered inferotemporally. The lid speculum was removed. Pred-G ointment and atropine solution were applied to the ocular surface. The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well. There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure.
## 286 PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:, General with an interscalene block.,COMPLICATIONS:, None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION: ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder. The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture. Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted. Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result. The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks. Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1. Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered. The clavicular head was noted to be intact. There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2. Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3. A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site. Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area. His right shoulder was identified, marked his appropriate surgical site after verification with the patient. He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team. He then received prophylactic antibiotics. A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment. At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes. The right upper extremity was then prepped and draped in the usual sterile fashion. Preoperative markings were still visible at this point. A deltopectoral incision was made utilizing the inferior portion. Dissection was carried down. The deltoid was retracted laterally. The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion. There was a small cuff of tissue left on the proximal humerus associated with the clavicular head. Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion. This allowed reapproximation of the retracted tendon to the tendon stump. At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site. At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone. For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded. The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair. At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation. Aggressive external rotation was not performed. The wound was then copiously irrigated. The cephalic vein was not injured during the case. The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips. Sterile dressing was then placed. Anesthesia was then performed, interscalene block. The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days. We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.
## 287 TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. She has now been put forward for operative intervention.,PREOP DIAGNOSIS: ,1. Patent ductus arteriosus.,2. Severe prematurity.,3. Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation. After completion of the procedure, left recurrent laryngeal nerve visualized and preserved. Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced. The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed. Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma. The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus. The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion. It was then test occluded and then interrupted with a medium titanium clip. There was preserved pulsatile flow in the descending aorta. The left recurrent laryngeal nerve was identified and preserved. With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers. The skin was closed with a running 6-0 Caprosyn suture. A sterile dressing was placed. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.
## 288 PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:, Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1. The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION: ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine. The patient received a venogram documenting patency of the subclavian vein. Skin incision with blunt and sharp dissection. Electrocautery for hemostasis. The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads. The leads were sequentially checked. Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava. Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture. Pocket was irrigated with antibiotic solution. The pocket was packed with bacitracin-soaked gauze. This was removed during the case and then irrigated once again. The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION: , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.
## 289 HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821. An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy. The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE: ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt. Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. The left-sided heart was fully saturated. The phasic right-sided and left-sided pressures were normal. The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. The branch pulmonary arteries appeared normal. There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. No evidence of residual left-to-right shunt. There is no change in right-sided pressures. There is a slight increase in the left-sided phasic pressures. Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1. Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS): ,Coil embolization of patent ductus arteriosus.,MANAGEMENT: ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. Further patient care be directed by Dr. X.,
## 290 PREOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS: ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital. This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention. He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam. Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum. Minimal cartilaginous pieces were at the patellar tendon. He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department. A thigh high tourniquet was placed. He is prepped and draped in the usual sterile manner. Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes. Straight incision is carried down through skin and subcutaneous tissue anteriorly. Hemostasis was controlled via electrocoagulation. Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape. The inferior pole was freshened up. Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer. This was tied over the bony bridge superiorly. There was excellent reduction of the tendon to the patella. Interrupted running #1-Vicryl suture was utilized for over silk. A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum. There was excellent repair. Copious irrigation was carried out. Tourniquet was dropped and hemostasis controlled via electrocoagulation. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin. Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing. Digits were warm and no brawny pulses present at the end of the case. The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion. He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair.
## 291 PREOPERATIVE DIAGNOSIS:, Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:, Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:, Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:, This 80-year-old woman has had some mild dementia. She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations. She was found to be hypercalcemic. Intact PTH was mildly elevated. A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.,FINDINGS AND PROCEDURE:, The patient was placed on the operating table in the supine position. A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan. The electronic medical record was reviewed as was the ultrasound. The patient was sedated. A small roll was placed behind the shoulders to moderately hyperextend the neck. The head was supported in a foam head cradle. The neck and chest were prepped with chlorhexidine and isolated with sterile drapes. After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma. The larger anterior neck veins were divided between 4-0 silk ligatures. Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection. The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally. The right sternothyroid muscle was divided transversely with the cautery. The right middle thyroid vein was divided between 4-0 silk ligatures. The right thyroid lobe was rotated leftward. Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified. This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed. It was sent for weight and frozen section. It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.,Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled "pre-excision." It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma. However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH. The neck was irrigated with saline and hemostasis found to be satisfactory. The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl. The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond. The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.
## 292 PREOPERATIVE DIAGNOSIS: , Abdominal mass.,POSTOPERATIVE DIAGNOSIS: , Abdominal mass.,PROCEDURE:, Paracentesis.,DESCRIPTION OF PROCEDURE: ,This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation. At the present time, the patient is under radiation treatment. Two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days. The cytology of the fluid was negative and the culture was also negative. Eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis.,The CAT scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size. Therefore, I called the patient home and she came to the emergency department where the service was provided. At that time, I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion. Unfortunately, the catheter was open. I did not have a drainage system at that time. So, I withdrew directly with a syringe 700 mL of clear fluid. The system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment. She was given an appointment to see me in the office next Monday, which is three days from now.
## 293 EXAM:, Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS: ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained. Ultrasound demonstrates free fluid in the abdomen. The area of interest was localized with ultrasonography. The region was sterilely prepped and draped in the usual manner. Local anesthetic was administered. A 5-French Yueh catheter needle combination was taken. Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle. A total of approximately 5500 mL of serous fluid was obtained. The catheter was then removed. The patient tolerated the procedure well with no immediate postprocedure complications.,IMPRESSION: , Ultrasound-guided paracentesis as above.
## 294 PREOPERATIVE DIAGNOSIS: , Phimosis.,POSTOPERATIVE DIAGNOSIS: , Phimosis.,PROCEDURE: , Reduction of paraphimosis.,ANESTHESIA: ,General inhalation anesthetic with 0.25% Marcaine, penile block and ring block about 20 mL given.,FLUIDS RECEIVED: , 100 mL.,SPECIMENS:, No tissues sent to pathology.,COUNTS: , Sponge and needle counts were not necessary.,TUBES/DRAINS: , No tubes or drains were used.,FINDINGS: , Paraphimosis with moderate swelling.,INDICATIONS FOR OPERATION: , The patient is a 15-year-old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution. When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis. The plan is for reduction.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis. Using Betadine and alcohol cleanse, we then did a dorsal penile block and a ring block by surgeon with 0.25% Marcaine, 20 mL were given. He did quite well after the procedure and was transferred to the recovery room in stable condition.
## 295 PROCEDURE PERFORMED: ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:, After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein. A steel guidewire was inserted through the needle into the vascular lumen without resistance. The needle was then removed over the guidewire and the guidewire was secured to the field. A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. A #11-knife blade was used to make a deeper incision. Hemostasis was made complete. The edges of the incision were grasped and retracted. Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. Metzenbaum scissors were then used to dissect cephalad to expose the guide wires. The guidewires were then pulled through the pacemaker pocket. One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. The guidewire and dilator were then removed. Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. The pacemaker lead was then placed in the appropriate position in the right ventricle. Pacing and sensing thresholds were obtained. The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. Pacing and sensing threshold were then reconfirmed. Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. The guidewire and dilator were then removed. Under fluoroscopic guidance, the atrial lead was passed into the right atrium. The sheath was then turned away in standard fashion. Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. Pacing and sensing thresholds were obtained. The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. Sensing and pacing thresholds were then reconfirmed. The leads were wiped free of blood and placed into the pacemaker generator. The pacemaker generator leads were then placed into pocket with the leads posteriorly. The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion. A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. Steri-Strips overlaid. A sterile gauge dressing was placed over the site. The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer: Medtronics.,Model: Sigma.,Model #: 1234.,Serial #: 123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,VENTRICULAR LEAD:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead: Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead: Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:, Pacing mode DDDR: Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:, Successful implantation of DDDR permanent pacemaker.,PLAN:,1. The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2. The patient will be placed on antibiotics for five days to avoid pacemaker infection.
## 296 PREOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,POSTOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,OPERATIVE PROCEDURE:, Insertion of transvenous pacemaker.,ANESTHESIA:, Local,PROCEDURE AND GROSS FINDINGS:, The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated. In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava. An introducer was then placed over the wire. The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area. ,The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples. Sterile dressings were placed, and the patient was returned to the ICU in good condition.
## 297 PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec. Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms. The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only. VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2. VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5. The patient is in normal sinus rhythm.,IMPRESSION: ,Normally functioning pacemaker ICD post implant day number 1.
## 298 PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS: ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a dual-chamber pacemaker.,2. Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Versed 2.5 mg.,2. Fentanyl 150 mcg.,3. Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. A guide wire was advanced into the vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision. A pocket was then fashioned in the medial direction. Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein. The dilator was then removed over the wire. A second wire was then advanced into the sheath into the left axillary vein. The sheath was then removed over the top of the two wires. One wire was then pinned to the drape. Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein. The dilator and wire were removed. A passive pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical location. Adequate pacing and sensing functions were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein. The wire and dilating sheaths were removed. An active pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. Preformed J stylet was then advanced into the lead. The lead was positioned in the appendage location. Lead body was then turned, and the active fix screw was fixed to the tissue. Adequate pacing and sensing function were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2. Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3. Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 534 ohms. P waves measured at 1.2 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,2. Right ventricular lead impedance 900 ohms. R-waves measured 6.0 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1. Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be taken back to her room for continued observation. She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Completion of the course of antibiotics.,4. Home dismissal instructions provided in written format.,5. Device interrogation in the morning.,6. Wound check in 7 to 10 days.,7. Enrollment in device clinic.
## 299 SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1. Left subclavian access under fluoroscopic guidance.,2. Left subclavian venogram under fluoroscopic evaluation.,3. Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4. Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5. Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL: ,The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt. The first attempt accessed the left subclavian artery. The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully. The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis. The patient went asystole during the procedure. The transcutaneous pacer was used. The patient was oxygenating well. The patient had several compression applied by the nurse. However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein. The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium. The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different. At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated. The stylet was removed. The R-wave measured at 40 millivolts. The impedance was 580 and the threshold was 1.3 volt. The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high. I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header. The pacemaker was single-chamber pacemaker Altura 60, serial number 123456. After that, the pacemaker was put in the pocket. Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute. The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION: ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure. No significant bleed.
## 300 CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.
## 301 REFERRAL INDICATION,1. Tachybrady syndrome.,2. Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a single-chamber pacemaker.,2. Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME: ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Ancef 1 g.,2. Benadryl 50 mg.,3. Versed 3 mg.,4. Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation. She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent. Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. Percutaneous access of the left axillary vein was then performed. A wire was then advanced in the left axillary vein using fluoroscopy. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein. The dilator and wire were removed. An active pacing lead was then advanced down in the right atrium. The peel-away sheath was removed. Lead was passed across the tricuspid valve and positioned in an apical septal location. This was an active fixed lead and the screw was deployed. Adequate pacing and sensing function were established. The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue. The pocket was washed with antibiotic-impregnated saline. A pulse generator was obtained and connected securely to the lead. The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2. Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:, Right ventricular lead impedance 630 ohms. R wave measures 17.5 mV. Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1. Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2. Chest x-ray to rule out pneumothorax and verify lead position.,3. Completion of course of antibiotics.,4. Device interrogation in the morning.,5. Home dismissal instructions provided in a written format.,6. Wound check in 7 to 10 days.,7. Enrollment in Device Clinic.
## 302 PREOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,PROCEDURE PERFORMED:,1. Third metatarsal osteotomy, right foot.,2. Talus bunionectomy, right foot.,3. Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal. In addition, she complains of a painful right talus bunion to the right foot. She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. The risks versus benefits of the procedure have been explained to the patient by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: ,After IV was established by the Department Of Anesthesia, the patient was taken to the operating room via cart. She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction. Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area. There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head. A previous cicatrix was noted with slight hypertrophic scarring. Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length. Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen. Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue. Any small traversing veins were ligated with electrocautery. Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue. Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified. A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues. Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal. McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed. A moderate amount of plantar adhesions were encountered. The third toe was plantar flex and the third metatarsal was delivered into the wound. Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw. The metatarsal head was allowed to float. The wound was flushed with copious amounts of sterile saline. #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained. Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique. Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal. There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively. A #10 blade was used to make a 3 cm incision through the skin. Next, a #15 blade was used to deepen the incision through the subcutaneous tissue. Next, the medial and lateral aspects were undermined. The abductor tendon was identified and retracted. A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone. The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis. A reciprocating rasp was used to smooth all bony prominences. The wound was flushed with copious amount of sterile saline. #3-0 Vicryl was used to close the capsuloperiosteal tissues. #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture. Next, #4-0 nylon was used to close the skin in a simple interrupted technique. Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head. A #15 blade was used to make a small linear incision under the third metatarsal head. The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa. The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee. Copious amounts of Webril were placed on all bony prominences. 3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast. One was able to insert two fingers to the distal and proximal aspects of the _cast. The capillary refill time to the digits was less than three seconds after cast application. The patient tolerated the above anesthesia and procedures without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She was given standard postoperative instructions to rest, ice and elevate her right foot. She was counseled on smoking cessation. She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain. She was given Keflex #30 1 p.o. t.i.d. She is to follow up with Dr. X on Monday. She is to be full weightbearing with a cast boot. She was given emergency contact numbers to call us if problem arises.
## 303 PREOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,PROCEDURE: , Open reduction and internal fixation of left distal radius.,IMPLANTS: ,Wright Medical Micronail size 2.,ANESTHESIA: , LMA.,TOURNIQUET TIME: , 49 minutes.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PATHOLOGY: , None.,TIME OUT: , Time out was performed before the procedure started.,INDICATIONS:, The patient was a 42-year-old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis. The patient was in early stage of gestation. Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor.,DESCRIPTION OF PROCEDURE: , Supine position, LMA anesthesia, well-padded arm, tourniquet, Hibiclens, alcohol prep, and sterile drape.,Exsanguination achieved, tourniquet inflated to 250 mmHg. First, under fluoroscopy the fracture was reduced. A 0.045 K-wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction. A 2-cm radial incision, superficial radial nerve was exposed and protected. Dissecting between the first and second dorsal extensor retinaculum, the second dorsal extensor compartment was elevated off from the distal radius. The guidewire was inserted under fluoroscopy. A cannulated drill was used to drill antral hole. Antral awl was inserted. Then we reamed the canal to size 2. Size 2 Micronail was inserted to the medullary canal. Using distal locking guide, three locking screws were inserted distally. The second dorsal incision was made. The deep radial dorsal surface was exposed. Using locking guide, two proximal shaft screws were inserted and locked the nail to the radius. Fluoroscopic imaging was taken and showing restoration of the height, tilt, and inclination of the radius. At this point, tourniquet was deflated, hemostasis achieved, wounds irrigated and closed in layers. Sterile dressing applied. The patient then was extubated and transferred to the recovery room under stable condition.,Postoperatively, the patient will see a therapist within five days. We will immobilize wrist for two weeks and then starting flexion-extension and prosupination exercises.
## 304 PREOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,OPERATION PERFORMED:, OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:, Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy. The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain. Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow. After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well.
## 305 PREOPERATIVE DIAGNOSIS: ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist. He was placed into a well-molded splint after reduction was performed in the emergency department. Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted. All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure. The right upper extremity was prepped and draped in a sterile fashion. A 5-cm incision was made over the flexor carpi radialis of the right wrist. The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus. Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue. Next, a reduction was performed placing the distal fragment into appropriate alignment. This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position. An Acumed Accu-lock plate was placed along the volar aspect of the distal radius. This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment. A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position. Two distal locking screws were placed along the plate itself. The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular. Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate. All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture. AP and lateral views were taken of these screw placements again. None of these screws were into the joint and all had appropriate length into the dorsal cortex. Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase. AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws. Bicortical purchase was appreciated and no screws were placed into the joint. The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint. The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.
## 306 PREOPERATIVE DIAGNOSIS:, Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,POSTOPERATIVE DIAGNOSIS:, Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,PROCEDURES:,1. Osteosynthesis of acetabular fracture on the left, complex variety.,2. Total hip replacement.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field. Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line. The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion. The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column. The major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws. It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface. Once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall. Once this was accomplished, the procedure was turned over to Dr. X and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same. This will be dictated in separate note. The patient tolerated the procedure well. The sciatic nerve was well protected and directly visualized to the level of the notch.
## 307 PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:, Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,PROCEDURES: ,1. Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2. Closed reduction casting of the right forearm.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.5% Marcaine.,TOURNIQUET TIME: , On the left was 29 minutes.,COMPLICATIONS: ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today. The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow. After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure. Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve. At that same time, the patient's mildly angulated radial shaft fracture will be reduced. This was explained to the father. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms. All questions were answered. The father agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The left upper extremity was then prepped and draped in the standard surgical fashion. Attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful. It was decided at this time that she would need open reduction. The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg. The Esmarch was then removed. An incision was then made. Care was taken to avoid any injury to the ulnar nerve. The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint. This was easily removed. The ulnar nerve was also identified, and appeared to be intact. The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place. After fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement. The wound was then irrigated with normal saline and closed using 2-0 Vicryl and 4-0 Monocryl. The wound was clean and dry, dressed with Steri-Strips and Xeroform. The area was infiltrated with 0.5% Marcaine. The patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation. The tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding. Attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed. The final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age. The patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days. The father was made aware of the intraoperative findings. All questions answered.
## 308 PREOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1. Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION FOR SURGERY: , The patient has had a longstanding history of foot problems. The foot problem has been progressive in nature and has not been responsive to conservative treatment. The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail. The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain. All questions were thoroughly answered. The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities. The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE: ,The patient was brought to the operating room and placed in a supine position. No tourniquet was utilized. IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site. The lower extremity was prepped and draped in the usual sterile manner. Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot. A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx. Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery. Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized. A linear periosteal capsular incision was made in line with the skin incision. The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface. Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head. The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition. The sesamoid was in satisfactory condition. An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration. Care was taken to preserve the sagittal groove. The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment. The access guide was noted to be in good position. A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed. The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal. The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head. The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment. It was then fixated with 1 screw. A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction. The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position. Compression and fixation were noted to be satisfactory. Inspection revealed good fixation and alignment at the operative site. Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally. All rough edges were rasped smooth. Examination revealed there was still lateral deviation of the hallux. A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:, Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux. The original skin incision was extended from the point just distal to the interphalangeal joint. All vital structures were identified and retracted. Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface. The focus of the deformity was noted to be more distal on the hallux. Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected. The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site. The alignment and contour of the first way was now satisfactorily improved. The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation. The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl. The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia. A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ACE wrap to provide mild compression. The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,A walker boot was dispensed and applied. The patient should wear it when walking or standing., ,The next office visit will be in 4 days. The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions. The patient was discharged home with vital signs stable in no acute distress.
## 309 PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope. He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture. He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass. His mandible fracture was not noted initially. The patient also has a history of prostate cancer and a renal cell carcinoma. The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending. The patient later saw a local oral surgeon. He diagnosed his mandible fracture and advised him to seek treatment in Houston. He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago. The patient had significant discomfort and could eat foods and drink fluids with difficulty. Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position. Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion. The patient was then prepped and draped in a manner consistent with sterile procedures. A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible. A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue. A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible. Electrocautery as well as 4.0 silk ties were used for hemostasis. A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site. The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound. Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis. Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site. Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site. When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically. All the screws were also locking screws. Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline. The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin. A sterile dressing was then placed over the incision. The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs. Estimated blood loss is 125 mL.
## 310 TITLE OF OPERATION:,1. Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture including skin, muscle, and bone using a Synthes 3.5 mm locking plate on the lateral malleolus and two Synthes 4.5 mm cannulated screws medial malleolus.,2. Closed reduction and screw fixation of right femoral neck fracture using one striker Asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3. Retrograde femoral nail using a striker T2 retrograde nail 10 x 340 with a 10 mm INCAP and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4. Irrigation and debridement of right knee.,5. Irrigation and debridement of right elbow abrasions.,PREOP DIAGNOSIS:,1. Right open ankle fracture.,2. Right femoral shaft fracture.,3. Right femoral neck fracture.,4. Right open knee.,5. Right elbow abrasions.,POSTOP DIAGNOSIS:,1. Right open ankle fracture.,2. Right femoral shaft fracture.,3. Right femoral neck fracture.,4. Right open knee.,5. Right elbow abrasions.,INTRAVENOUS FLUIDS: , 650 packed red blood cells.,TOURNIQUET TIME: , 2 hours.,URINE OUTPUT: ,1600 cubic centimeters.,ESTIMATED BLOOD LOSS: , 250 cubic centimeters.,COMPLICATIONS:, None.,PLAN:, non-weightbearing right lower extremity, clindamycin x 48 hours.,OPERATIVE NARRATIVE:, The patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries. She sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions. Given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention. The risks of surgery were discussed in detail and the consents were signed. The operative site was marked. The patient was taken to the operating room where she was given preoperative clindamycin. The patient had then general anesthetic performed by anesthesia.,A well-padded side tourniquet was placed. Attention was turned to the right ankle first. The large medical laceration was extended and the tissues were debrided. All dirty of the all injured bone, muscle, and tissues were debrided. Wound was then copiously irrigated with 8 liters of normal saline. At this point, the medial malleolus fracture was identified and was reduced. This was then fixed in with two 4.5 mm cannulated Synthes screws.,Next, the attention was turned to lateral malleolus. Incision was made over the distal fibula. It was carried down sharply through the skin in the subcutaneous issues. Care was taken to preserve the superficial peroneal nerve. The fracture was identified, and there was noted to be very comminuted distal fibula fracture. The fracture was reduced and confirmed with fluoroscopy. A 7 hole Synthes 3.5 mm locking plate was placed. This was placed in a bridging fashion with three screws above and three screws below the fracture. Appropriate reduction was confirmed under fluoroscopy. A cotton test was performed, and the ankle did not open up. Therefore, it was decided not to proceed with syndesmotic screw.,Next, the patient was then placed in the fracture table and all extremities were well padded. All prominences were padded. The right leg was then prepped and draped in usual sterile fashion. A 2-cm incision was made just distal to the greater trochanter. This was carried down sharply through the skin to the fascia. The femur was identified. The guidewire for a striker Asnis 6.5 mm screw was placed in the appropriate position. The triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws. A reduction of the fracture was performed prior to placing all the guide wires. A single 8 mm Asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,Next, the abrasions on the right elbow were copiously irrigated. The necrotic and dead tissue was removed. The abrasions did not appear to enter the joints. They were wrapped with Xeroform 4 x 4 x 4 Kerlix and Ace wrap.,Next, the lacerations of the anterior knee were connected and were extended in the midline. They were carried down sharply to the skin and the retinacular issues to the joint. The intercondylar notch was identified. A guide wire for the striker T2 retrograde nail was placed and localized with fluoroscopy. The opening reamer was used following the bolted guide wire was then passed. The femur was then sequentially reamed using the flexible reamers. A T2 retrograde nail 10 x 340 was then passed. Two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,Prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline. Any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,The patient was placed in the AO splints for the right ankle. The wounds were dressed with Xeroform 4 x 4 x 4s and IO band. The care was then transferred for the patient to Halstead Service.,The plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,Dr. X was present and scrubbed for the entirety of the procedure.
## 311 PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS: ,Fracture dislocation, C2.,OPERATION PERFORMED,1. Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2. Posterior spinal instrumentation C1-C3, using Synthes system.,3. Posterior cervical fusion C1-C3.,4. Insertion of morselized allograft at C1to C3.,ANESTHESIA:, GETA.,ESTIMATED BLOOD LOSS:, 100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:, Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:, The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture. This is secondary to a motor vehicle accident and it was translated appropriately 1 cm. Risks and benefits have been conferred with the patient as well as the family, they wish to proceed. The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5. The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties. Spinal cord monitoring was induced. No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately. This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes. The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls. The patient's Mayfield tongue was fixated in the usual standard fashion. The patient was subsequently prepped and draped in the usual sterile fashion. Midline incision was extended from the base of the skull down to the C4 spinous process. Full thickness skin fascia developed. The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed. Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally. Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2. Good placement was seen both in the AP and lateral planes using fluoroscopy. Facet screws were then placed at C3. Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made. This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory. A 14 x 3.5 mm screws were then placed appropriately. Lateral masteries at C1 endplate were placed appropriately. The medial and lateral borders were demarcated with a Penfield. The great occipital nerve was retracted out the way. Starting point was made with a high-speed power bur and midline and lateral mass bilaterally. Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory. Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately. Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately. Once this was done, all end caps were appropriately torqued. This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment. It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access. Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2. The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3. Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements. The fascia was closed using interrupted #1 Vicryl suture figure-of-8. Superficial drain was placed appropriately. Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes. The subcutaneous tissues were closed using a #2-0 Vicryl suture. The dermal edges were approximated using staples. The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately. The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position. Mayfield tongues were subsequently released. No significant bleeding was appreciated. The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition. No complications arose.
## 312 PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1. Open reduction and internal screw fixation right fifth metatarsal.,2. Application of short leg splint.,ANESTHESIA:, TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal. The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot. She continued to walk on the foot and found nothing was wrong despite the pain. She was recently seen by Dr. X and was referred to Dr. Y for surgery. The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y. The consent is available on the chart for review. The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL: ,After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in the supine position. A safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied. After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and a sterile stocking was reflected. Attention was directed to the right fifth metatarsal base. The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal. An avulsion fracture of the right fifth metatarsal base was visualized. The fracture was linear in nature from distal lateral to proximal medial. There appeared to be a pseudoarthrosis on the lateral view. A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve. A linear incision was created with a #10 blade. A #15 blade was used to deepen the incision through the subcutaneous tissue. All small veins traversing the subcutaneous tissue were ligated with electrocautery. Next, using combination of sharp and blunt dissection, the deep fascia was reached. Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade. Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone. The fracture site was not clearly visualized due to bony callus. A #25 gauge needle was introduced into the fracture site under fluoroscopy. The fracture site was easily found. An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone. Next, a small ball burr was used to resect the remaining hypertrophic bone. Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone. Next, a bone clamp was applied and the fracture was reduced. Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally. A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly. All this was done under fluoroscopy. Next, the wound was flushed with copious amounts of sterile saline. The fracture site was found to have rigid compression. The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed. Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion. A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique. Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique. A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance. A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot. Next, copious amounts of Webril were applied to pad all bony prominences. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits. Next, 4-inch, pre-moulded, well-padded posterior splint was applied. The capillary refill time of the digits was less than three seconds. The patient tolerated the above anesthesia and procedure without complications. After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone. She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches. She will rest, ice, and elevate her right leg. She is to follow up in the clinic on 08/26/03 at 10:30 a.m.. She was given emergency contact numbers and will call or return if problems arise earlier.
## 313 PREOPERATIVE DIAGNOSIS: , Left lateral malleolus fracture.,POSTOPERATIVE DIAGNOSIS:, Left lateral malleolus fracture.,PROCEDURE PERFORMED: , Open reduction and internal fixation of left lateral malleolus.,ANESTHESIA: ,General.,TOURNIQUET TIME: , 59 minutes.,COMPLICATIONS: , None.,BLOOD LOSS: , Negligible.,CLOSURE: , 2-0 Vicryl and staples.,INDICATIONS FOR SURGERY:, This is a young gentleman with soccer injury to his left ankle and an x-ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF. The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently.,OPERATIVE PROCEDURE: , The patient was taken to the operative room where general anesthesia was successfully introduced. The right ankle was prepped and draped in standard fashion. The tourniquet was applied about the right upper thigh. An Esmarch tourniquet was used to exsanguinate the ankle. The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes. An approximately 6 inch longitudinal incision was made just over the lateral malleolus. Care was taken to spare overlying nerves and vessels. An elevator was used to expose the fracture. The fracture was freed of old hematoma and reduced with a reducing clamp. An interfragmentary cortical screw was placed of 28 mm with excellent purchase. The intraoperative image showed excellent reduction. A 5-hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally. Excellent stability of fracture was achieved. Final fluoroscopy showed a reduction to be anatomic in 2 planes. The wound was irrigated with copious amounts of normal saline. Deep tissue was closed with 2-0 Vicryl. The skin was approximated with 2-0 Vicryl and closed with staples. Dry sterile dressing was applied.,The patient tolerated the procedure, was awakened and taken to the recovery room in stable condition.
## 314 PREOPERATIVE DIAGNOSIS:, Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:, Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:, Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE: ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness. He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder. He was worked up by the emergency department. His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage. Oral maxillary facial surgery was consulted to manage the mandible fracture. After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures. Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital. He was laid in supine position on the operating room table. ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion. The surgeon approached the operating room table in a sterile fashion. Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion. Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior. This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth. The patient was manipulated up into maximum intercuspation. He has a malocclusion with severe bruxism and so wear facets were lined up. This was secured with 26-gauge surgical steel wire. Attention was then directed to the symphysis extraorally. Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made. Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible. The periosteum was incised and reflected with the periosteal elevator. The fracture was noted and it was displaced. Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned. This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws. The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture. Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule. After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified. It was noted that the fracture went through tooth #17 and this needed to be extracted. Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots. The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed. The fracture was noted to be well reduced. The wound was then irrigated with copious amount of sterile water. The patient was released for excellent intercuspation. He was then manipulated up into the occlusion easily. Wound was then closed with running 3-0 chromic gut suture. Attention was then directed extraorally. This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin. Attention was then again directed into the mouth. The throat pack was removed and orogastric tube was placed and stomach content was evacuated. The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions. At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.
## 315 PREOPERATIVE DIAGNOSIS: , Left tibial tubercle avulsion fracture.,POSTOPERATIVE DIAGNOSIS:, Comminuted left tibial tubercle avulsion fracture with intraarticular extension.,PROCEDURE:, Open reduction and internal fixation of left tibia.,ANESTHESIA: , General. The patient received 10 ml of 0.5% Marcaine local anesthetic.,TOURNIQUET TIME: , 80 minutes.,ESTIMATED BLOOD LOSS:, Minimal.,DRAINS: , One JP drain was placed.,COMPLICATIONS: , No intraoperative complications or specimens. Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw and one 45, 60 mm partially threaded cortical screw and 2 washers.,HISTORY AND PHYSICAL:, The patient is a 14-year-old male who reported having knee pain for 1 month. Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee. The patient was seen at an outside facility where he was splinted and subsequently referred to Children's for definitive care. Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta. Surgery is recommended to the grandmother and subsequently to the father by phone. Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal. Risks of surgery include the risks of anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab. All questions were answered, and father and grandmother agreed to the above plan.,PROCEDURE: , The patient was taken to the operating and placed supine on the operating table. General anesthesia was then administered. The patient was given Ancef preoperatively. A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh. The patient's extremity was then prepped and draped in the standard surgical fashion. Midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in Esmarch. Finally, the patient had tourniquet that turned in 75 mmHg. Esmarch was then removed. The incision was then made. The patient had significant tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement. We were able to see the underside of the anterior horn of both medial and lateral meniscus. The intraarticular cartilage was restored using two 45 K-wires. Final position was checked via fluoroscopy and the corners were buried in the cartilage. There was a large free floating metaphyseal piece that included parts of proximal tibial physis. This was placed back in an anatomic location and fixed using a 45 cortical screw with a washer. The avulsed fragment with the patellar tendon was then fixed distally to this area using a 6.5, 60 mm cancellous screw with a washer. The cortical screw did not provide good compression and fixation at this distal fragment. Retinaculum was repaired using 0 Vicryl suture as best as possible. The hematoma was evacuated at the beginning of the case as well as the end. The knee was copiously irrigated with normal saline. The subcutaneous tissue was re-approximated using 2-0 Vicryl and the skin with 4-0 Monocryl. The wound was cleaned, dried, and dressed with Steri-Strips, Xeroform, and 4 x4s. Tourniquet was released at 80 minutes. JP drain was placed on the medium gutter. The extremity was then wrapped in Ace wrap from the proximal thigh down to the toes. The patient was then placed in a knee mobilizer. The patient tolerated the procedure well. Subsequently extubated and taken to the recovery in stable condition.,POSTOP PLAN: ,The patient hospitalized overnight to decrease swelling and as well as manage his pain. He may weightbear as tolerated using knee mobilizer. Postoperative findings relayed to the grandmother. The patient will need subsequent hardware removal. The patient also was given local anesthetic at the end of the case.
## 316 PREOPERATIVE DIAGNOSIS:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1. Open reduction internal fixation of the talus.,2. Medial malleolus osteotomy.,3. Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:, 50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:, A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament. There was no evidence of osteochondral defects of the talar dome.,HISTORY: ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement. There was no open injury. The patient fell approximately 10 feet off his liner, landing on his left foot. There was evidence of gross deformity of the ankle. An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture. He was distal neurovascularly intact. The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body. Because of its tenuous blood supply, the patient is at risk for avascular necrosis. The patient has agreed to undergo the above-named procedure and consent was obtained. All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03. A spinal anesthetic was administered. A nonsterile tourniquet was placed on the left upper thigh, but not inflated. He was then positioned on the beanbag. The extremity was then prepped and draped in the usual sterile fashion for this procedure. An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg. At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site. At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus. This was curved anteromedial along the root of the saphenous vein. The saphenous vein was located. Its tributaries going plantar were cauterized and the vein was retracted anterolaterally. At this time, we identified the medial malleolus. There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus. This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem. It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact. This pedicle was the anterior portion of the deltoid ligament. At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus. Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply. This provided us with excellent exposure to the fracture site of the medial side. At this time, any loose comminuted pieces were removed. The dome of the talus was also checked and did not reveal any osteochondral defects. There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site. It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site. At this time, a reduction was performed. The #7-0 partially threaded cannulated screws were used in order to fix the fracture. At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site. Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in. A depth gauze was then used to measure screw length. A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw. A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site. Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction. This projection gave us excellent view of our screw placement and excellent compression across the fracture site. At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft. This was placed using a freer elevator into the fracture site where the comminution was. At this time, we copiously irrigated the wound. The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps. Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws. Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury. A tight repair was performed of the deltoid ligament. At this time, again copious irrigation was used to irrigate the wound. A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision. At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied. The patient was then placed in a plaster splint for mobilization. The tourniquet was then released. The patient was then transferred off the operating table to recovery in stable condition. The prognosis for this fracture is guarded. There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk. The patient is aware of this and he will be followed as an outpatient for this problem.
## 317 OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating room table. The patient was prepped and draped in usual sterile fashion. An incision was made in the groin crease overlying the internal ring. This incision was about 1.5 cm in length. The incision was carried down through the Scarpa's layer to the level of the external oblique. This was opened along the direction of its fibers and carried down along the external spermatic fascia. The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free. A hernia sac was identified and the testicle was located. Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring. This was performed by incising the transversalis fascia circumferentially. The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity. Care was taken not to injure the testicular vessels. Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance. The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high. This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum. The testicle was viable. This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum. A small 1 cm incision was made in the anterior superior scrotal wall. Dissection was carried down through the dartos layer. A subdartos pouch was formed with blunt dissection. The hemostat was then pushed against the tissues and this tissue was divided. The hemostat was then passed through the incision. A Crile hemostat was passed back up into the inguinal canal. The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision. The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle. The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture. Benzoin and a Steri-Strip were placed. Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly. This was done with 2 to 3 interrupted 3-0 silk sutures. The external oblique was then closed with interrupted 3-0 silk suture. The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch. Benzoin and Steri-Strip were applied. The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.
## 318 PREOPERATIVE DIAGNOSES:,1. Displaced intraarticular fracture, right distal radius.,2. Right carpal tunnel syndrome.,PREOPERATIVE DIAGNOSES:,1. Displaced intraarticular fracture, right distal radius.,2. Right carpal tunnel syndrome.,OPERATIONS PERFORMED:,1. Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2. Right carpal tunnel release.,ANESTHESIA: , General.,CLINICAL SUMMARY: , The patient is a 37-year-old right-hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago. This was an intraarticular four-part fracture that was displaced dorsally. In addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop. She is admitted for reconstructive operation. The symptoms of carpal tunnel were present preop and worsened after the injury.,OPERATION:, The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia. Once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner. Tourniquet was placed around the right upper extremity. The upper extremity was then elevated and exsanguinated using an Esmarch dressing. The tourniquet was elevated to 250 mmHg. The entire operation was performed with 4.5 loop magnification. At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally. This was carried down to the flexor carpi radialis, which was then retracted ulnarly. The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles. The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin. It was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced. This was an intraarticular four-part fracture. Under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced. Then, 2.06 two-inch K-wires were drilled radial into the volar ulnar fragment and then a second K-wire was then drilled from the dorsal radial to the dorsal ulnar piece. A third K-wire was then drilled from the volar radial to the dorsal ulnar piece. The fracture was then manipulated. The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it. Further K-wires were then placed through the radial styloid into the proximal fragment. A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K-wires. At this time, the distal screws were then placed. The distal screws were the small screws. These were non-locking screws, all eight screws were placed. They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth. Again, these were 18-20 mm screws. After placing three of the screws it was necessary to remove the K-wires. There was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture. After the distal screws were placed, the fracture was reduced and held in place with K-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit. The screws were then placed. These were 12 mm screws. They were placed 4 in number. The K-wires were then removed. Finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist. This was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure. It was dissected free from the structure out to its trifurcation. The motor branches seen entering the thenar fascia and obstructed. The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm. In this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon. Incisions were then copiously irrigated with normal saline. Homeostasis was maintained with electrocautery. The pronator quadratus was closed with 3-0 Vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion. A large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position. The tourniquet was let down. The fingers were immediately pink. The patient was awakened and taken to the recovery room in good condition. There were no operative complications. The patient tolerated the procedure well.
## 319 PREOPERATIVE DIAGNOSIS: ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum. Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses. There is a hernia on the left side. The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table. General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically. A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision. An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia. External ring was exposed with dissection as well. The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal. The testes were freed with dissection by removing cremasteric and spermatic fascia. The hernia sac was separated from the cord, twisted and suture ligated at the internal ring. Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring. However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided. This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel. The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures. The skin was approximated with interrupted #5-0 chromic catgut sutures. Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good. Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture. Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion. However, on this side, there was no inguinal hernia. The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side. The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure. Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision. The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition. Instrument and sponge counts were correct. There were no apparent complications. Estimated blood loss was less than 20 to 30 mL.
## 320 PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE: ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007. While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture. This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius. The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions. He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago. The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8. The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware. He is taking a job out of state in the next couple of months. Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously. The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout. The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient. A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers. A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator. The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment. The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment. At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws. The ulnar styloid was not affixed in any portion of this repair. The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order. The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order. Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw. Three screws were locking across the die-punch fragment. The remaining two screws were placed into the radial shaft. All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial. The tourniquet time was 1.5 hours. At this point, the tourniquet was let down. The entire construct was irrigated with copious amounts of bacitracin and normal saline. Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound. Several image intensification x-rays were taken at the conclusion of the case to check screw length. Screw lengths were changed out during the case as needed based on the x-ray findings. The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex. A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint. Estimated blood loss was 10 mL. There were no specimens. Tourniquet time was 1.5 hours.
## 321 PREOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,POSTOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,PROCEDURE:, Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture (27513).,OPERATIVE FINDINGS:, He had intercondylar split, and then he had a medial Hoffa fracture. He also had some comminution of the medial femoral condyle which prohibited an anatomic key between the two segments of the medial condyle.,IMPLANTS:, We used 2.4 and 3.5 cortical screws, as well as a LISS Synthes femoral locking plate.,COMPLICATIONS:, None.,IV FLUIDS:, 2000,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 40 mL,URINE OUTPUT:, 650,HISTORY: ,This 45-year-old male had a ground-level fall, sustaining this injury. He was admitted for definitive operative fixation. Risks and benefits were discussed, he agreed to go ahead with the procedure.,DESCRIPTION OF THE OPERATION:, The patient was identified in preop holding, then taken to the operating room. Once adequate anesthesia was obtained, his left lower extremity was prepped and draped in a routine sterile fashion. He was given antibiotics. He placed a traction pin through his proximal tibia, and pulled weight off the end of the bed. I made a midline approach and then did the lateral parapatellar arthrotomy. We excised some of the fat pad to give us better visibility into the notch. We excised a good bit of his synovium and synovial pouch. At this time we were able to identify the fracture fragments. Again, there was an intercondylar split and then two free pieces of the medial condyle. The femur fracture was very distal through the metaphysis. At this time we thoroughly cleaned out all the clot between all the fracture fragments and cleaned the cortical margins.,Next we began the reduction. There was no reduction key between the two segments of the Hoffa fracture. Therefore, we reduced the anterior portion of the medial condyle to the lateral condyle, held it with point-of-reduction clamp and K-wires, and then secured it with 2.4 mini fragment lag screws. Next, with this medial anterior piece in place, we had some contour over the notch with which we were able to reduce the posterior medial Hoffa fragment. This gave us a nice notch contour. Again, there was some comminution laterally so that the fracture between the Hoffa segments did not have a perfect key. Once we had it reduced, based on the notch reduction, we then held it with K-wires. We secured it with two 3.5 cortical screws from the lateral condyle into this posterior segment. We then secured it with 2.4 cortical screws from the anterior medial to the posterior medial segment just subchondral. Then, finally, we secured it with a 3.5 cortical screw from the anterior medial to the posterior medial piece. All screws ran between and out of the notch.,With the condyle now well reduced, we reduced it to the metaphysis. We slid a 13-hole LISS plate submuscularly. We checked on AP and lateral views that showed we had good reduction of the fracture and appropriate plate placement. We placed the tip threaded guidewire through the A-hole of the plate jig and got it parallel to the joint. We then clamped the plate down to the bone. Proximally, we made a stab incision for the trocar at the 13-hole position, placed our tip threaded guidewire in the lateral aspect of the femur, checked it on lateral view, and had it in good position.,With the jig in appropriate position and clamped, we then proceeded to fill the distal locking screws to get purchase into the condyles. We then placed multiple unicortical locking screws in the shaft and metaphyseal segment. Our most proximal screw was proximal to the tip of the prosthesis.,At this time we took the jig off and put the final screw into the A-hole of the plate. We then took final C-arm views which showed we had a good reduction on AP and lateral views, the plate was in good position, we had full range of motion of the knee, and good reduction clinically and radiographically. We then pulse lavaged the knee with 3 liters of fluid. We closed the quad tendon and lateral retinaculum with interrupted 0 Vicryl over a Hemovac drain. Subdermal tissue was closed with 2-0 Vicryl, skin with staples. Sterile dressing and a hinged knee brace were applied. The patient was awakened from anesthesia and taken to Recovery in stable condition.,PLAN:,1. Nonweightbearing for 3 months.,2. CPM for 0 to 90 degrees as tolerated.
## 322 PREOPERATIVE DIAGNOSIS: , Right undescended testis (ectopic position).,POSTOPERATIVE DIAGNOSES:, Right undescended testis (ectopic position), right inguinal hernia.,PROCEDURES: , Right orchiopexy and right inguinal hernia repair.,ANESTHESIA:, General inhalational anesthetic with caudal block.,FLUIDS RECEIVED: ,100 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS:, No tissues sent to pathology.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION: ,The patient is an almost 4-year-old boy with an undescended testis on the right; plan is for repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room; surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. He was then placed in the supine position and sterilely prepped and draped. Since the testis was in the ectopic position, we did an upper curvilinear scrotal incision with a 15-blade knife and further extended it with electrocautery. Electrocautery was also used for hemostasis. A subdartos pouch was then created with a curved tenotomy scissors. The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments. As we were dissecting it, we then found the testis itself into the sac, and we opened the sac, and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment, not being attached to the top. We then dissected the hernia sac off of the testis __________ some traction using the straight Joseph scissors and straight and curved mosquito clamps. Once this was dissected off, we then twisted it upon itself, and then dissected it down towards the external ring, but on traction. We then twisted it upon itself, suture ligated it with 3-0 Vicryl and released it, allowing it to spring back into the canal. Once this was done, we then had adequate length of the testis into the scrotal sac. Using a curved mosquito clamp, we grasped the base of the scrotum internally, and using the subcutaneous tissue, we tacked it to the base of the testis using a 4-0 chromic suture. The testis was then placed into the scrotum in the proper orientation. The upper aspect of the pouch was closed with a pursestring suture of 4-0 chromic. The scrotal skin and dartos were then closed with subcutaneous closure of 4-0 chromic, and Dermabond tissue adhesive was used on the incision. IV Toradol was given. Both testes were well descended in the scrotum at the end of the procedure.
## 323 PREOPERATIVE DIAGNOSIS: , Left undescended testis.,POSTOPERATIVE DIAGNOSIS:, Left undescended testis plus left inguinal hernia.,PROCEDURES:, Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.,ABNORMAL FINDINGS:, A high left undescended testis with a type III epididymal attachment along with vas.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS RECEIVED: ,1100 mL of crystalloid.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:, Sponge and needle counts were correct x2.,SPECIMENS,: No tissues sent to Pathology.,ANESTHESIA:, General inhalational anesthetic.,INDICATIONS FOR OPERATION: , The patient is an 11-1/2-year-old boy with an undescended testis on the left. The plan is for repair.,DESCRIPTION OF OPERATION:, The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then placed in a supine position, and sterilely prepped and draped. A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15-blade knife and further extended with electrocautery into the subcutaneous tissue. We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring. We were able to dissect all the way up to the ring, but were unable to get the testis delivered. We then made a left inguinal incision with a 15-blade knife, further extending with electrocautery through Scarpa fascia down to the external oblique fascia. The testis again was not visualized in the external ring, so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15-blade knife further extending with Metzenbaum scissors. The testis itself was quite high up in the upper canal. We then dissected the gubernacular structures off of the testis, and also, then opened the sac, and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors. Once this was dissected off and up towards the internal ring, it was twisted upon itself and suture ligated with an 0 Vicryl suture. We then dissected the lateral spermatic fascia, and then, using blunt dissection, dissected in the retroperitoneal space to get more cord length. We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off. We then found that we had an adequate amount of cord length to get the testis in the mid-to-low scrotum. The patient was found to have a type III epididymal attachment with a long looping vas, and we brought the testis into the scrotum in the proper orientation and tacked it to mid-to-low scrotum with a 4-0 chromic stay stitch. The upper aspect of the subdartos pouch was closed with a 4-0 chromic pursestring suture. The testis was then placed into the scrotum in the proper orientation. We then placed the local anesthetic, and the ilioinguinal nerve block, and placed a small amount in both incisional areas as well. We then closed the external oblique fascia with a running suture of 0-Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure. The Scarpa fascia was closed with a 4-0 chromic suture, and the skin was closed with a 4-0 Rapide subcuticular closure. Dermabond tissue adhesive was placed on the both incisions, and IV Toradol was given at the end of the procedure. The patient tolerated the procedure well, was in a stable condition upon transfer to the recovery room.
## 324 PREOPERATIVE DIAGNOSIS:, Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:, Right undescended testicle.,OPERATIONS:,1. Right orchiopexy.,2. Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis. The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding. The testis was identified right at the external inguinal ring. The testis was unable to be brought down into the scrotal sac. The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown. Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed. Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed. The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in the inguinal and scrotal area. After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal. The incision came through the subcutaneous tissue and external oblique fascia was identified. The external oblique fascia was opened sharply and was taken all the way down towards the external ring. The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture. After dissecting proximally, the testis was identified in the distal end of the inguinal canal. The testis was pulled up. The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring. There was very small hernia, which was removed and was tied at the base. PDS suture was used to tie this hernia sac all the way up to the base. There was a Y right at the vas and cord indicating there was enough length into the scrotal sac. The testis was easily brought down into the scrotal sac. One centimeter superior scrotal incision was made and a Dartos pouch was created. The testicle was brought down into the pouch and was placed into the pouch. Careful attention was done to ensure that there was no torsion of the cord. The vas was medial all the way throughout and the cord was lateral all the way throughout. The epididymis was in the posterolateral location. The testicle was pexed using 4-0 Vicryl into the scrotal sac. Skin was closed using 5-0 Monocryl. The external oblique fascia was closed using 2-0 PDS. Attention was drawn to re-create the external inguinal ring. A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord. Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia. After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion. Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable. It was smaller than the other side, probably by 50%. There were no palpable testicular masses. Plan was for the patient to follow up with us in about 1 month. The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours. No tub bath for 2 months. The patient and family understood all the instructions.
## 325 PREOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA: ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA. The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology. The patient states that this was started approximately 24 hours ago. The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain. The patient admits to poor dental hygiene. Denies any recent or dental abscesses in the past. The patient is a substance abuser, does admit to smoking cocaine approximately three days ago. The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted. After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE: ,The patient was brought in upright and supine position. Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side. This was done at the base of #18, #19, and #20 teeth. After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control. After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed. There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination. The patient understood consequences of her actions. Does state that she does not care at this time and just wants to be left alone. At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin. The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.
## 326 PREOPERATIVE DIAGNOSIS:, Nonpalpable right undescended testis.,POSTOPERATIVE DIAGNOSIS: , Nonpalpable right undescended testis with atrophic right testis.,PROCEDURES: , Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUID RECEIVED: ,250 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMEN:, The tissue sent to Pathology was right testicular remnant.,ABNORMAL FINDINGS:, Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring. Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring.,INDICATIONS FOR OPERATION: , The patient is a 2-year-old boy with a right nonpalpable undescended testis. The plan is for evaluation and repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. The patient was placed in supine position and examined. The left testis well within scrotum. The right was again not palpable despite the patient being asleep with multiple attempts to check.,The patient was then sterilely prepped and draped. An 8-French feeding tube was then placed within his bladder through the urethra and attached to the drainage. We then incised the infraumbilical area once he was sterilely prepped and draped, with 15 blade knife, then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3-0 Monocryl. We entered the peritoneum with the 5-mm one-step system. We then used the short 0-degree lens for laparoscopy. We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg. There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found. Because there was no testis found in the abdomen, we then evacuated the gas and closed the fascial sheath with the 3-0 Monocryl tacking sutures. Then skin was closed with subcutaneous closure of 4-0 Rapide. A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery. Electrocautery was used for hemostasis. A curved tenotomy scissor was used to open the sac. The tunica vaginalis was visualized and grasped and then dissected up towards external ring. There was no apparent testicular tissue. We did remove it, however, tying off the cord structure with a 4-0 Vicryl suture and putting a tagging suture at the base of the tissue sent. We then closed the subdartos area with the subcutaneous closure of 4-0 chromic. We then did a similar curvilinear incision on the left side for testicular fixation. Delivered the testis into the field, which had a type III epididymal attachment and was indeed about 3 to 4 mL in size, which was larger than expected for the patient's age. We then closed the upper aspect of the subdartos pouch with the 4-0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos, skin, and subcutaneous closure with 4-0 chromic on left hemiscrotum. At the end of the procedure, the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure. The patient tolerated procedure well, and was in stable condition upon transfer to the recovery room.
## 327 TITLE OF OPERATION: , Right frontal side-inlet Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. Recommendation was for an Ommaya reservoir. Risks and benefits have been explained. They agreed to proceed.,PREOP DIAGNOSIS: , Leukemic meningitis.,POSTOP DIAGNOSIS: ,Leukemic meningitis.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of laryngeal mask airway, positioned supine on a horseshoe headrest. The right frontal region was prepped and draped in the usual sterile fashion. Next, a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line. Once this was completed, a burr hole was then created with a high-speed burr. The dura was then coagulated and opened. The Ommaya reservoir catheter was inserted up to 6.5 cm. There was good flow. This was connected to the side inlet, flat-bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision. This was then cut and __________. It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies. Wound was then irrigated copiously with __________ irrigation, closed using 3-0 Vicryl for the deep layers and 4-0 Caprosyn for the skin. The connection was made with a 3-0 silk suture and was a right-angle intermediate to hold the catheter in place.
## 328 PREOPERATIVE DIAGNOSIS:, Ectopic left testis.,POSTOPERATIVE DIAGNOSIS: , Ectopic left testis.,PROCEDURE PERFORMED: , Left orchiopexy.,ANESTHESIA: , General. The patient did receive Ancef.,INDICATIONS AND CONSENT: , This is a 16-year-old African-American male who had an ectopic left testis that severed approximately one-and-a-half years ago. The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle. The risks, benefits, and alternatives of the proposed procedure were discussed with the patient. Informed consent was on the chart at the time of procedure.,PROCEDURE DETAILS: ,The patient did receive Ancef antibiotics prior to the procedure. He was then wheeled to the operative suite where a general anesthetic was administered. He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure. Next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region. The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery. The fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors. This was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord. With this accomplished, the testis was then identified. It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord. Once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens. Weitlaner retractor was placed to provide further exposure. There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with #3-0 Vicryl. Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis. Next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment. This was taken down to approximately the two-thirds length of the left scrotal compartment. Once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision. A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment. Once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the Iris scissors. A dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision. A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord. With this accomplished, #3-0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis. The sutures were then tied creating the orchiopexy. The remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed Monocryl in a horizontal mattress fashion interrupted sutures. Once again hemostasis was maintained with Bovie electrocautery. Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures. External ring was then recreated and grasped on each side with hemostats and approximated with #3-0 Vicryl in a running fashion cephalad to caudad. Once this was created, the created ring was inspected and there was adequate room for the cord. There appeared to be no evidence of compression. Finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed Vicryl in a running subcuticular fashion. The patient had been injected with bupivacaine prior to closing the skin. Finally, the patient was cleansed.,The scrotal support was placed and plan will the for the patient to take Keflex one tablet q.i.d. x7 days as well as Tylenol #3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum. He will follow up with Dr. X in 10 to 14 days. Appointment will be made.
## 329 BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,: The patient is placed in the supine position, prepped and draped in the usual manner. Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision. Hemostasis was obtained with the Bovie and the spermatic cord was identified. It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief. The left testicle was delivered through the same incision. The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine. The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin. A dry sterile dressing fluff and scrotal support applied over that. The patient was sent to the Recovery Room in stable condition.
## 330 PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1. Incision and drainage, left elbow.,2. Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION: ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage. He was then scheduled for I&D and excision of the bursa. Risks and benefits were discussed. No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine. The left upper extremity was prepped and draped in standard sterile fashion. On examination of the left elbow, there was presence of thickening of the bursal sac. There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted. An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin. The incision was carried proximally and distally. The olecranon bursa was significantly thickened and scarred. Excision of the olecranon bursa was performed. There was significant evidence of thickening of the bursa with some evidence of adhesions. Satisfactory olecranon bursectomy was performed. The wound margins were debrided. The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution. There was no evidence of a loose body. There was no bleeding or drainage. After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion. The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing. Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias. The patient tolerated the procedure very well. He was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noticed.
## 331 PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:, Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:, The patient has had a longstanding history of foot problems. The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care. The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed. The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain. All questions were thoroughly answered. The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities. The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE: ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure. The patient was brought to the operating room and placed in the supine position. Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected. The lower extremity was prepped and draped in the usual sterile manner. Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot. The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band. A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel. Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band. The lateral plantar fascial band was left intact. Visualization and finger probe confirmed adequate transection. The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples. The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression. The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact. A walker boot was dispensed and applied. The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days. The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions. After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.
## 332 PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: ,Gallbladder.,BRIEF HISTORY: ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture. The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department. Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure. The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain. During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder. The patient did well postdrainage. The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp. However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003. A HIDA scan had been performed, which showed no cystic duct obstruction. A tube cholecystogram was performed, which showed no cystic or common duct obstruction. There was abnormal appearance of the gallbladder, however, the pathway was patent. Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy. Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS: ,The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder. The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family. The patient was brought to the operating room after an epidural was performed per anesthesia. Local anesthesia was given with 1% lidocaine. A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel. Next, hemostasis was obtained using electro Bovie cautery. Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel. Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered . The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view. Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified. The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors. The cystic duct was identified. A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors. The gallbladder was then removed from the liver bed using electro Bovie cautery. A plane was created. The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel. The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections. Permanent sections are still pending. The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen. The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures. Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.
## 333 PROCEDURE PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was then placed in a modified lithotomy position taking great care to pad all extremities. TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis. Antibiotics were given for prophylaxis against surgical infection.,A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg. A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 4 other 10/11 mm trocars were placed. Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line. All of the trocars were placed without difficulty. The patient was then placed in reverse Trendelenburg position.,The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula. The gastrohepatic ligament was then identified and incised in an avascular plane. The dissection was carried anteromedially onto the phrenoesophageal membrane. The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice. This incision was extended to the right to allow identification of the right crus. Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus. The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve. This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,Attention was next turned to the left anterolateral aspect of the esophagus. At its left border, the left crus was identified. The dissection plane between it and the left aspect of the esophagus was freed. The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch. By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,The next step consisted of mobilization of the gastric pouch. This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel. This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade. The esophagus was lifted by a Babcock inserted through the left upper quadrant port. Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall. Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus. A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus. The retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired. Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,The last part of the operation consisted of the passage and fixation of the antireflux valve. With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left. It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap. The,52-French bougie was used to calibrate the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
## 334 PREOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,PROCEDURE,1. Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2. Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure. The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region. This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease. The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion. The area was dressed with antibiotic ointment and then a Peri-Pad. The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes. Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex. Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized. Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple. At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple. When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft. At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola. At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic. The areolar skin graft was pie crusted. Then, at this point, the area of areola was dressed with silicone gel sheeting. A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position. Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made. The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out. When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision. Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola. The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.
## 335 PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient underwent general anesthesia with endotracheal intubation. An orogastric was placed and a Foley catheter placed. He was placed in a modified flank position with the hips rotated to 45 degrees. Pillow was used to prevent any pressure points. He was widely shaved, prepped, and draped. A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus. The incision was made through the premarked site through the skin and subcutaneous tissue. The aponeurosis of the external oblique was incised in the direction of its fibers. Muscle-splitting incision was made in the internal oblique and transversus abdominis. The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring. Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions. Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially. This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava. Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed. The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery. The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device. After the arteries had been divided, the renal vein was divided again using a stapling device. The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed. Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel. Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion. The estimated blood loss was negligible. There were no complications. The patient tolerated the procedure well and left the operating room in satisfactory condition.
## 336 PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago. The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction. Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed. The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space. The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space. During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved. The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed. The ureter was encountered during the course of resection, but was not ligated. The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS: 900 mL.
## 337 PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.
## 338 PREOPERATIVE DIAGNOSIS:, Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2. 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1. Repair of nerve and tendon, right ring finger.,2. Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME: ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION: ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle. The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well. The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room and placed in the supine position. All bony prominences were adequately padded. Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time. The right upper extremity was prepped and draped in the usual sterile fashion. The hand was inspected. Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture. The sutures were removed and the wound was explored. It was found that the ulnar digital neurovascular bundle was 100% transected. The radial neurovascular bundle on the right ring finger was found to be completely intact. We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP. We copiously irrigated the wound. Repair was undertaken of the FDS with #3-0 undyed Ethibond suture. The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact. Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair. Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury. The digital nerve was dissected proximally and distally to likely visualize the nerve. The nerve was then approximated using microvascular technique with #8-0 nylon suture. The hands were well approximated. The nerve was not under undue tension. The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture. Sterile dressing was placed and a dorsal extension Box splint was placed. The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition. Overall prognosis is good.
## 339 PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:, 250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:, General endotracheal.,COMPLICATIONS: , None.,DRAINS: , Included a JP drain in the right flank as well as a #16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 60-year-old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter. I had a long discussion with him concerning variety of options. We talked in particular about extirpated versus ablative surgery. Based on his young age and excellent state of health, decision was made at this point to proceed to a right partial nephrectomy laparoscopically. All questions were answered, and he wished to proceed with surgery as planned. Note that the patient does have a positive family history of renal cell carcinoma.,PROCEDURE IN DETAIL: , After acquisition of proper informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table. After institution of adequate general anesthetic via endotracheal rod, he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest. All pressure points were carefully padded, and he was securely taped to the table. Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia. His abdomen was then prepped and draped in a standard surgical fashion. Note that a #16-French Foley catheter was in place per urethra as well as an orogastric tube. The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident. We then placed a Visiport 10 x 12 trocar in the right lateral abdomen. With the trocar in place, we were able to place the remaining trocars under direct laparoscopic visualization. We placed three additional trocars. An 11 mm screw type trocar at the umbilicus, a 6 screw type trocar 7 cm in the midline above the umbilicus, and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline.,The procedure was begun by reflecting the right colon by incising the white line of Toldt. The colon was reflected medially, and the retroperitoneum was exposed on that side. This was a fairly superficial lesion, so decision was made in advance to potentially not perform vascular clamping, however, I did feel it important to get high level control prior to proceeding to the partial. With the colon reflected, the duodenum was identified, and it was reflected medially under Kocher maneuver. The ureter and gonadal vein were identified on the right side and elevated. The space between the ureter and the gonadal vein was then developed, and the gonadal vein was dropped elevating only the ureter, and carrying this plane dissection up towards the renal hilum. Once we got up to the renal hilum, we were able to skeletonize the renal hilar vessels partially, and in particular, we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs. The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device.,With the kidney free and the hilum prepared, the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma, and using this approach, we were able to identify the 2-cm, right renal mass located in the lower pole laterally. A cap of fat was left overlying this mass. Based on the position of the mass, we performed intraoperative laparoscopic ultrasound, which showed the mass to be somewhat deeper than initially anticipated. Based on this finding, I decided to go ahead and clamp the renal hilum during resection. A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc. Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure, and he also received Lasix prior to clamping the renal hilum. With the renal hilum clamped, we did resect the tumor using cold scissors. There was somewhat more bleeding than would be expected based on the hilar clamping; however, we were able to successfully resect this lesion. We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section. With the tumor resected, the base of the resection was then cauterized using the Argon beam coagulator, and several bleeding vessels were oversewn using figure-of-eight 3-0 Vicryl sutures with lap ties for tensioning. We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure. We then released the vascular clamp. Total clamp time was 11 minutes. There was minimal bleeding and occlusion of this maneuver, and after unclamping the kidney, the kidney pinked up appropriately and appeared well perfused after removal of the clamp. We then replaced the kidney within its Gerota envelope and closed that with 3-0 Vicryl using lap ties for tensioning. A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2-0 nylon. The specimen was placed into a 10-mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm. It was evaluated on the table and passed off the table for Pathology to evaluate. They stated that the tumor was close to the margin, but there appeared to be 1-2 mm normal parenchyma around the tumor. In addition, the frozen section biopsies from the base of the resection were negative for renal cell carcinoma. Based on these findings, the lower most trocar site was closed using a running 0 Vicryl suture in the fascia. We then re-insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis. Any bleeding points were controlled primarily using bipolar cautery or hemoclips. The area was copiously irrigated with normal saline. The colon was then replaced into its normal anatomic position. The mesentry was evaluated. There were no defects noted. We closed the 10 x 12 lateral most trocar site using a Carter-Thompson closure device with 0-Vicryl. All trocars were removed under direct visualization, and the abdomen was desufflated prior to removal of the last trocar. The skin incisions were irrigated with normal saline and infiltrated with 0.25% Marcaine, and the skin was closed using a running 4-0 Monocryl in subcuticular fashion. Benzoin and Steri-Strips were placed. The patient was returned in supine position and awoken from general anesthetic without incident. He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring. At the end of the case, sponge, instrument, and needle counts were correct. I was scrubbed and present throughout the entire case.
## 340 PREOPERATIVE DIAGNOSIS:, Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:, Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:, 100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA: ,General endotracheal.,DRAINS:, 16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass. This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma. I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy. All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:, After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table. Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia. After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest. All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure. Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage. The abdomen was insufflated in the right outer quadrant. Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy. The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident. We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus. Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed. Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar. There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt. This exposed the retroperitoneum on the right side. The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only. We then identified the ureter and gonadal vein in the retroperitoneum. The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum. Sequential packets of tissue were taken using primarily the LigaSure Atlas device. Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins. We proceeded then and skeletonized the structures into four individual packets. We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland. The adrenal was spared during this procedure. There was no contiguous connection between the renal mass and a right adrenal gland. This plane of dissection was taken down primarily using the LigaSure device. We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring. Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments. The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected. The kidney was then freed within the retroperitoneum. A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction. We extended the lower most trocar site approximately 6 cm to facilitate extraction. The kidney was removed and passed off the table as a specimen for pathology. This was bivalved by pathology, and we reviewed the specimen.
## 341 PREOPERATIVE DIAGNOSIS: , Morton's neuroma, third interspace, left foot.,POSTOPERATIVE DIAGNOSIS:, Morton's neuroma, third interspace, left foot.,OPERATION PERFORMED: , Excision of neuroma, third interspace, left foot.,ANESTHESIA: , General (local was confirmed by surgeon).,HEMOSTASIS: , Ankle pneumatic tourniquet 225 mmHg.,TOURNIQUET TIME: , 18 minutes. Electrocautery was necessary.,INJECTABLES: , 50:50 mixture of 0.5% Marcaine and 1% Xylocaine, both plain. Also, 0.5 mL dexamethasone phosphate (4 mg/mL).,INDICATIONS: , Please see dictated H&P for specifics.,PROCEDURE: ,After proper identification was made, the patient was brought to the operating room and placed on the table in supine position. The patient was then placed under general anesthesia. A local block was then injected into the third ray of the left foot. The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique. The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated. Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace. The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures. Identification of the neuroma was made following plantar flexion of the digits. It was grasped with a hemostat and it was dissected in toto and removed. It was then sent to pathology. The area was then flushed with copious amounts of sterile saline. Closure was with 4-0 Vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin. Steri-Strips were then placed over that area. A sterile compressive dressing consisting of saline-soaked gauze, ABD, Kling, Coban was placed over the foot. The tourniquet was then released. Good flow was noted to return to all digits. The patient did tolerate the procedure well. He left the operating room with all vital signs stable and neurovascular status intact. The patient went to the recovery. The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain. The patient will follow up with me in approximately 4 days for dressing change.
## 342 PREOPERATIVE DIAGNOSIS:, Suspicious microcalcifications, left breast.,POSTOPERATIVE DIAGNOSIS:, Suspicious microcalcifications, left breast.,PROCEDURE PERFORMED:, Needle-localized excisional biopsy, left breast.,ANESTHESIA:, Local with sedation.,SPECIMEN: ,Left breast with specimen mammogram.,COMPLICATIONS:, None.,HISTORY: , The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast. She had no palpable mass on physical exam. She does have significant family history with two daughters having breast cancer. The patient also has a history of colon cancer. A surgical biopsy was recommended and she was scheduled electively.,PROCEDURE:, After proper informed consent was obtained, she was placed in the operative suite. This occurred after undergoing preoperative needle localization. She was placed in the operating room in the supine position. She was given sedation by the Anesthesia Department. The left breast was prepped and draped in the usual sterile fashion. The skin was infiltrated with local and a curvilinear incision was made in the left lower outer quadrant. The breast tissue was grasped with Allis clamps and a core of tissue was removed around the localization wire. There were some fibrocystic changes noted. The specimen was then completely removed and was sent to Radiology for mammogram. The calcifications were seen in specimen per Dr. X. Meticulous hemostasis was achieved with electrocautery. The area was irrigated and suctioned.,The aspirant was clear. The skin was then reapproximated using #4-0 undyed Vicryl in a running subcuticular fashion. Steri-Strips and sterile dressing on the patient's bra were applied. The patient tolerated the procedure well and was transferred to recovery room in stable condition.
## 343 PREOPERATIVE DIAGNOSIS:, Refractory urgency and frequency.,POSTOPERATIVE DIAGNOSIS: , Refractory urgency and frequency.,OPERATION: , Stage I and II neuromodulator.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid. The patient was given Ancef preop antibiotic. Ancef irrigation was used throughout the procedure.,BRIEF HISTORY: , The patient is a 63-year-old female who presented to us with urgency and frequency on physical exam. There was no evidence of cystocele or rectocele. On urodyanamcis, the patient has significant overactivity of the bladder. The patient was tried on over three to four different anticholinergic agents such as Detrol, Ditropan, Sanctura, and VESIcare for at least one month each. The patient had pretty much failure from each of the procedure. The patient had less than 20% improvement with anticholinergics. Options such as continuously trying anticholinergics, continuation of the Kegel exercises, and trial of InterStim were discussed. The patient was interested in the trial. The patient had percutaneous InterStim trial in the office with over 70% to 80% improvement in her urgency, frequency, and urge incontinence. The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator. Risks of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed. Risk of failure of the procedure in the future was discussed.,Risk of lead migration that the treatment may or may not work in the long-term basis and data on the long term were not clear were discussed with the patient. The patient understood and wanted to proceed with stage I and II neuromodulator. Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR. The patient was placed in prone position. A pillow was placed underneath her pelvis area to slightly lift the pelvis up. The patient was awake, was given some MAC anesthesia through the IV, but the patient was talking and understanding and was able to verbalize issues. The patient's back was prepped and draped in the usual sterile fashion. Lidocaine 1% was applied on the right side near the S3 foramen. Under fluoroscopy, the needle placement was confirmed. The patient felt stimulation in the vaginal area, which was tapping in nature. The patient also had a pressure feeling in the vaginal area. The patient had no back sensation or superficial sensation. There was no sensation down the leg. The patient did have __________, which turned in slide bellows response indicating the proper positioning of the needle. A wire was placed. The tract was dilated and lead was placed. The patient felt tapping in the vaginal area, which is an indication that the lead is in its proper position. Most of the leads had very low amplitude and stimulation. Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks. Please note that the lidocaine was injected prior to the tunneling. A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead. Screws were turned and they were dropped. Attention was made to ensure that the lead was all the way in into the InterStim. Irrigation was performed after placing the main unit in the pouch. Impedance was checked. Irrigation was again performed with antibiotic irrigation solution. The needle site was closed using 4-0 Monocryl. The pouch was closed using 4-0 Vicryl and the subcutaneous tissue with 4-0 Monocryl. Dermabond was applied.,The patient was brought to recovery in a stable condition.
## 344 PREOPERATIVE DIAGNOSIS: ,Left breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:, Left breast mass with abnormal mammogram.,PROCEDURE PERFORMED:, Needle-localized excisional biopsy of the left breast.,ANESTHESIA:, Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Breast mass.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,INTRAOPERATIVE FINDINGS: , The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.,BRIEF HISTORY:, The patient is a 62-year-old female who presented to Dr. X's office with an abnormal mammogram showing a suspicious area on the left breast with microcalcifications and a nonpalpable mass. So the patient was scheduled for a needle-localized left breast biopsy.,PROCEDURE:, After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought to the operating suite. After IV sedation was given, the patient was prepped and draped in normal sterile fashion. Next, a curvilinear incision was made.,After anesthetizing the skin with 0.25% Marcaine and 1% lidocaine mixture, an incision was made with a #10 blade scalpel. The lesion with needle was then grasped with an Allis clamp. Using #10 blade scalpel, the specimen was colonized out and sent to Radiology for confirmation. Next, hemostasis was obtained using electrobovie cautery. The skin was then closed with #4-0 Monocryl suture in running subcuticular fashion. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was sent to Recovery in stable condition.
## 345 PREOPERATIVE DIAGNOSIS:, Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:, Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY: ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy. Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy. Potential complications include but are not limited to,,1. Infection.,2. Bleeding.,3. Postoperative pain.,4. Herniation from the incision.,PROCEDURE IN DETAIL:, Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room. General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position. A left flank incision was made over the area of the twelfth rib. The subcutaneous space was opened by using the Bovie. The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie. The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered. Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified. The peritoneum was swept medially. The Finochietto retractor was then placed for exposure. The kidney was readily identified and was mobilized from outside Gerota's fascia. The ureter was dissected out easily and was separated with a vessel loop. The superior aspect of the kidney was mobilized from the superior attachment. The pedicle of the left kidney was completely dissected revealing the vein and the artery. The artery was a single artery and was dissected easily by using a right-angle clamp. A vessel loop was placed around the renal artery. The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney. The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor. Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor. Bulldog clamp was then placed on the renal artery. The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex. This was performed by using the blunted end of the scalpel. The tumor was removed easily. The argon beam coagulation device was then utilized to coagulate the base of the resection. The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture. The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through. Two horizontal mattress sutures were placed and were tied down. The Gerota's fascia was then also closed by using 2-0 Vicryl suture. The area of the kidney at the base was covered with Surgicel prior to tying the sutures. The bulldog clamp was removed and perfect hemostasis was evident. There was no evidence of violation into the calyceal system. A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision. The drain was anchored by using silk sutures. The flank fascial layers were closed in three separate layers in the more medial aspect. The lateral posterior aspect was closed in two separate layers using Vicryl sutures. The skin was finally reapproximated by using metallic clips. The patient tolerated the procedure well.
## 346 PREOPERATIVE DIAGNOSIS: , Left renal mass, left renal bleed.,POSTOPERATIVE DIAGNOSIS: ,Left renal mass, left renal bleed.,PROCEDURE PERFORMED: , Left laparoscopic hand-assisted nephrectomy.,ANESTHESIA:, General endotracheal.,EBL: , 100 mL.,The patient had a triple-lumen catheter A-line placed.,BRIEF HISTORY:, The patient is a 54-year-old female with history of diabetic nephropathy, diabetes, hypertension, left BKA, who presented with abdominal pain with left renal bleed. The patient was found to have a complex mass in the upper pole and the lower pole of the kidney. MRI and CAT scan showed questionable renal mass, which could be malignant. Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy. At this point, the patient was unable to go home. The patient continually complained of pain. The patient required about 3 to 4 units of blood transfusions prior. The patient initially came in with hemoglobin less than 5. The hemoglobin prior to surgery was 10.,Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, respiratory failure, morbidity and mortality of the procedure due to her low ejection fraction were discussed. Cardiac clearance was obtained. The patient was high risk, family and the patient knew about the risk. The recommendation from the pulmonologist, cardiologist, and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention. The patient and family understood all the risks and benefits in order to proceed with the surgery.,DETAILS OF THE PROCEDURE:, The patient was brought to the OR. Anesthesia was applied. The patient had A-line triple-lumen catheter. The patient was placed in left side up, right side down oblique position. All the pressure points were well padded. The right fistula was carefully padded completely around it. Axilla was protected. The fistula was checked throughout the procedure to ensure that it was stable. The arms, ankles, knees, and joints were all padded with foam. The patient was taped to the table using 2-inch wide tape. OG and a Foley catheter were in place. A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply. There were some adhesions where the omentum was into the umbilical hernia, which was completely stuck. The omentum was released out of that just so we could obtain pneumoperitoneum. Pneumoperitoneum was obtained after using GelPort. Two 12-mm ports were placed in the left anterior axillary line, and mid clavicular line. The colon was reflected medially. Kidney was dissected laterally behind and inferiorly. There was large hematoma visualized with significant amount of old blood, which was irrigated out. Dissection was carried superiorly and the spleen was reflected medially. The spleen and colon were all intact at the end of the procedure. They were stable all throughout. Using endovascular GIA stapler, all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve. Hemostasis was obtained. The renal vein and the renal artery were stapled and there was excellent hemostasis.,The dissection was carried lateral to the adrenal and medial to the right kidney. The adrenal was preserved. The entire kidney was removed through the hand port. Irrigation was performed. There was excellent hemostasis at the end of the nephrectomy. Fibrin glue and Surgicel were applied just in case the patient had delayed DIC. The colon was placed back and 12-mm ports were closed under direct palpation using 0 Vicryl. The fascia was closed using loop #1 PDS in a running fashion and was tied in the middle. Please note that prior to the fascial closure, the peritoneum was closed using 0 Vicryl in running fashion. The subcuticular tissue was brought together using 4-0 Vicryl. The skin was closed using 4-0 Monocryl. Dermabond was applied. The patient was brought to the recovery in a stable condition.
## 347 PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:, Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1. Left neck mass biopsy.,2. Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:, After obtaining an informed, the patient was taken to the operating room where a time-out process was followed. Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room. Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation. The neck was prepped and draped in the usual fashion. I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap. Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass. The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck. A wedge sample was sent to Pathology for frozen section. At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen. Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements. This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface. There, there were some attachments to branches of the external carotid artery, which had to be suture ligated. At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck. This worked out quite nicely. The external jugular vein was out of the way, so initially we did not deal with it. We proceeded to tackle the area III and extended into II-A. When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise. Also, I felt that the submaxillary gland was enlarged. At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle. At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination. Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen. Hemostasis was revised and found to be adequate. The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap. The flap was replaced in its position. A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin. I would like to mention that also the facial vein was excised and the external jugular vein was ligated. It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it. A pressure dressing was applied.,The patient tolerated the procedure well. Estimated blood loss was no more than 100 mL. The patient was extubated in the operating room and sent for recovery.
## 348 PREOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,OPERATION PERFORMED,1. Nasal septoplasty.,2. Bilateral submucous resection of the inferior turbinates.,3. Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction. He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis. He also has developed tremendous edema to his posterior palate and uvula, which is causing choking. Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION: ,The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL. Afrin-soaked pledgets were placed in the nasal cavity bilaterally. The face was prepped with pHisoHex and draped in a sterile fashion. A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel. Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion. The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope. Hemostasis was acquired by using suction electrocautery. The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture. The table was then turned. A shoulder roll placed under the shoulders and the face was draped in a clean fashion. A McIvor mouth gag was applied. The tongue was retracted and the McIvor was gently suspended from the Mayo stand. The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion. The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion. The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery. The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion. Copious saline irrigation of the oral cavity was then performed. There was no further identifiable bleeding at the termination of the procedure. The estimated blood loss was less than 10 mL. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications.
## 349 PREOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1. Left midface elevation with nasolabial fold elevation.,2. Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service. The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity. In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry. The patient was seen in consultation and felt to be a surgical candidate for improvement. Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication. The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table. Dose of antibiotics was given to the patient. Compression devices were placed on the lower extremities to prevent the knee embolic events. The patient was turned to 180 degrees. The ETT tube was secured and the area was then prepped and draped in usual sterile fashion. A head wrap was then placed on the position and we then began our local. Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access. Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves. This was done bilaterally. We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue. We continued down to the lateral orbital rim until we identified periosteum. We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially. Care was taken to preserve the infraorbital nerve and that was visualized after elevation. We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw. After this was then carried out, we then clipped and cut as well as the end of the screw. Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl. Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry. Excess skin along the incision was then removed as well the skin from just lateral to the canthus. Care was taken to leave the orbicularis muscle down. We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case. A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour. This was carried out using a 15 blade down to subcutaneous tissue. The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture. At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally. As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision. We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only. This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease. Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements. Dr. Y was available and participated in the portions of the case as well.
## 350 PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA: ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection. He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer. Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the table was then turned. A shoulder roll placed under the shoulders and the face was placed in an extended fashion. The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion. A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode. Subplatysmal superior and inferior flaps were raised. The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4. The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck. This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region. The submandibular gland was removed as well. The X, XI, and XII cranial nerves were preserved. The internal jugular vein and carotid artery were preserved as well. Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure. There were two obviously positive nodes in this neck dissection. One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2. A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature. The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples. A fluff and Kling pressure dressing was then applied. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications.
## 351 PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED: ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS: ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast. After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity. This too was excised.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room, placed in supine position in the operating table. Intravenous sedation was administered by the Anesthesia Department. The Kopans wire was trimmed to an appropriate length. The patient was sterilely prepped and draped in the usual manner. Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision. A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire. The wire was stabilized and brought to protrude through the incision. Skin flaps were then generated with electrocautery. A generous core tissue was grasped with Allis forceps and excised with electrocautery. Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short. The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along. The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm. On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen. Hemostasis was obtained with electrocautery. Good hemostasis was obtained. The incision was closed in two layers. The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl. The second layer consisted of Steri-Strips on the epidermis. A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied. The patient tolerated the surgery well.
## 352 PREOPERATIVE DIAGNOSES:,1. Chronic nasal obstruction secondary to deviated nasal septum.,2. Inferior turbinate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1. Chronic nasal obstruction secondary to deviated nasal septum.,2. Inferior turbinate hypertrophy.,PROCEDURE PERFORMED:,1. Nasal septal reconstruction.,2. Bilateral submucous resection of the inferior turbinates.,3. Bilateral outfracture of the inferior turbinates.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS: , Minimal less than 25 cc.,INDICATIONS: , The patient is a 51-year-old female with a history of chronic nasal obstruction. On physical examination, she was derived to have a severely deviated septum with an S-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,PROCEDURE: ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained. The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away. Nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities. These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution. The nasal pledgets were then reinserted as the patient was prepped in the usual fashion. The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% Marcaine solution. The nasal vestibules were then cleansed with a pHisoHex solution. A #15 blade scalpel was then used to make an incision along the length of the caudal septum. The mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor. Once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a Cottle. At this point it should be mentioned that the patient's septum was significantly deviated with a large S-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity. Again, the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur. At this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur. Again, the mucosal flap was elevated in the right nasal septum. Now Knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a Takahashi forceps. A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side. Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel. Once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms. Therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone. The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone. Once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages. Inspection revealed very patent and nonobstructive nasal passages. Now the caudal incision was reapproximated with #4-0 chromic suture. Finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion. Finally, Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident.
## 353 PREOPERATIVE DIAGNOSES:, Tearing, eyelash encrustation with probable tear duct obstruction bilateral.,POSTOPERATIVE DIAGNOSES: ,1. Distal nasolacrimal duct stenosis with obstruction, left eye.,2. Distal nasolacrimal duct stenosis with obstruction, right eye.,OPERATIVE PROCEDURE: , Bilateral nasolacrimal probing.,ANESTHESIA: , Monitored anesthesia care along with mask sedation.,INDICATIONS FOR SURGERY: , This young infant is a 19-month-old who has had persistent tearing and mild eyelash encrustation of each eye for many months. Conservative measures at home have failed to completely resolve the symptoms. He has been placed on previous antibiotics treatment for presumed conjunctivitis. Please refer to clinic note for more details. Conservative measures at home have failed to resolve the symptoms. A nasolacrimal probing was offered as an elective procedure. Procedure as well as inherent risks, expected outcomes, benefits, and alternatives (including continued observation) were discussed with his mother prior to scheduling surgery. Again, a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure. The risks as explained included, but were not limited to temporary bleeding, persistent symptoms, recurrence need for further procedure, possible need for future stent placement or repeat probing, and anesthesia risk were all discussed. Also a rare possibility of errant passage of the nasolacrimal probe was discussed. Preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome/result from surgery. No guarantees were offered. Informed consent was signed and placed on the chart.,DESCRIPTION OF PROCEDURE: ,The patient was identified and the procedure was verified. Procedure as well as inherent risks were again discussed with parents prior to the procedure. After anesthesia was induced in the operating room, tetracaine drops were applied to each eye and the pressure of the eyes were checked with Tono-Pen. The pressure on the right was 17 mmHg and on the left was 16 mmHg.,A punctal dilator was then used to dilate the left superior puncta. A size 00 Bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally. The probe was advanced until a firm stop of the lacrimal bone was felt. The probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct. A mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve. There was also some mild stenosis distally, but not felt significant. The probe was used to navigate through this mild resistance. A second Bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency. Both probes were removed. The 00 Bowman probe was then used to navigate the inferior puncta canaliculus system. Patency was confirmed. The left upper lid was everted and inspected and was found to be normal.,Attention was then turned to the right side where the similar procedure through the right superior puncta was performed. A punctal dilator was used to dilate the puncta followed by a size 00 Bowman probe. Again on this side, a size 0 Bowman probe was unable to be placed initially to the superior puncta. The probe was used to navigate the superior puncta, canaliculus, and then the probe was rotated superomedially and the probe was advanced. Similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt. The mild resistance was over come at the approximate location of the valve. Metal-on-metal feel confirmed patency through the right naris with a second metal probe. At the completion of the procedure all probes were removed. Awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,Postoperative instructions were provided to the parents by me, and the discharging nurse. I did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily. Technique explained and demonstrated. Erythromycin ointment to both eyes twice daily for three days. Follow up was arranged and he may call with any further questions or concerns.
## 354 PREOPERATIVE DIAGNOSES: ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:, The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes. At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction. There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established. The right ear was draped in normal sterile fashion. Cerumen was removed from the external canal. The extruding Santa Barbara T-tube was identified and atraumatically removed. A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified. With a mask anesthetic, the eardrum elevated. A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated. A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied. Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.
## 355 PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:, Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball. He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion. Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve. Further up, the cartilaginous septum was displaced to the left of the maxillary crest. There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made. Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate. Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut. The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides. The maxillary crest was removed with a gouge. Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected. Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures. The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected. The right nasal bone was depressed and left nasal bone was wide. Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities. The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment. Approximate blood loss was 10 to 20 mL.
## 356 PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1. Bilateral myringotomies.,2. Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:, None.,FINDINGS: ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same. At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:, With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides. Bilateral inferior radial myringotomies were performed, first on the right and then on the left. Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side. Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally. At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.
## 357 PREOPERATIVE DIAGNOSES: ,1. Chronic eustachian tube dysfunction.,2. Retained right pressure equalization tube.,3. Retracted left tympanic membrane.,4. Dizziness.,POSTOPERATIVE DIAGNOSES:,1. Chronic eustachian tube dysfunction.,2. Retained right pressure equalization tube.,3. Retracted left tympanic membrane.,4. Dizziness.,PROCEDURE:,1. Removal of the old right pressure equalizing tube with placement of a tube. Tube used was Santa Barbara.,2. Myringotomy with placement of a left pressure equalizing tube. The tube used was Santa Barbara.,ANESTHESIA:, General.,INDICATION: , This is a 98-year-old female whom I have known for several years. She has a marginal hearing. With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly. So, we have kept sets of tubes in her ears at all times. The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed. There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia. Mask airway was used. IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant. In the same area, a small Santa Barbara tube was placed. This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated. Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis. Anterior, inferior incision was made. Tympanic membrane bounced back to neutral position. A Santa Barbara tube was cut to the 80% of the original length and placed in the hole. Ciprofloxacin drops were placed in the ear. Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:, None.,DISPOSITION:, To PACU in a stable condition.
## 358 PROCEDURE PERFORMED:,1. Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2. PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile manner. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein. Through the arterial sheath, angiography of the right common femoral artery was obtained. Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained. Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique. Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view. Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS: ,1. LV-gram: LVEDP was 15 mmHg. LV ejection fraction 10% to 15% with global hypokinesis. Only anterior wall is contracting. There was no mitral regurgitation. There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2. The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated. The left main coronary artery calcified vessel with disease.,2. The left anterior descending artery had an 80% to 90% mid-stenosis. First diagonal branch had a more than 90% stenosis.,3. The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery. The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle. The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire. The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min. Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch. The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD. The stent delivery balloon was used to post-dilate the overlapping segment. The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres. At this point, it was noted that the left main had a retrograde dissection. A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery. The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery. Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained. Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained. Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability. The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened. From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes. The right common femoral artery and vein sheaths were both sutured in place for further observation. Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1. Left ventricular dysfunction with ejection fraction of 10% to 15%.,2. High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications. The estimated blood loss was 200 ml. Estimated dye used was 200 ml of Visipaque. The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN: ,1. Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2. Hydration.,3. The patient will be observed over night for any hemodynamic instability or ischemia. If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.
## 359 PREOPERATIVE DIAGNOSES:, Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,POSTOPERATIVE DIAGNOSES:, Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,OPERATION: , Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.,ANESTHESIA: ,General via facemask.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: , None.,INDICATIONS: ,The patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.,PROCEDURE: , The patient was brought to the operating room, was placed in supine position. General anesthesia was begun via face mask technique. Once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal. A small amount of wax was removed with a loop. A 4-mm operating speculum was then introduced. An anteroinferior quadrant radial myringotomy was then performed. A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft. Reuter bobbin PE tube was then inserted, followed by Floxin otic drops and a cotton ball in the external meatus. Head was then turned to the opposite side, where similar procedure was performed. Once again, the middle ear cleft had a mucoid effusion. A tube was inserted to an anteroinferior quadrant radial myringotomy.,Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.
## 360 PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:, Basal Cell CA.,LOCATION: , Mid parietal scalp.,PREOP SIZE:, 1.5 x 2.9 cm,POSTOP SIZE:, 2.7 x 2.9 cm,INDICATION:, Poorly defined borders.,COMPLICATIONS:, None.,HEMOSTASIS:, Electrodessication.,PLANNED RECONSTRUCTION:, Simple Linear Closure.,DESCRIPTION OF PROCEDURE:, Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
## 361 OPERATIONS,1. Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3. Posterior leaflet abscess resection.,ANESTHESIA: ,General endotracheal anesthesia,TIMES: ,Aortic cross-clamp time was ** minutes. Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the patient's chest and legs were prepped and draped in standard surgical fashion. A #10-blade scalpel was used to make a midline median sternotomy incision. Dissection was carried down to the level of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw, and full-dose heparinization was given. Next, the chest retractor was positioned. The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned. We then prepared to place the patient on cardiopulmonary bypass. A 2-0 Ethibond double pursestring was placed in the ascending aorta. Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine. Next, double cannulation with venous cannulas was instituted. A 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our SEC cannula. This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit. Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium. Through this was passed our inferior vena cava cannula. This was likewise connected to the Y connection of our venous cannula portion. We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted. Cardiopulmonary bypass was instituted. Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape. Sondergaard's groove was taken down. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. This was connected appropriately as was the retrograde cardioplegia catheter. Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole. Next a #15-blade scalpel was used to open the left atrium. The left atrium was decompressed with pump sucker. Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view. Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it. The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk. After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel. Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture. This was done so as to reconstruct the posterior annular portion. Prior to doing so, care was taken to remove any debris and abscess-type material. The pledgeted stitch was lowered into place and tied. Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it. This was done without difficulty. The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle. There was noted to be a small amount of central regurgitation. It was felt that this would be corrected with our annuloplasty portion of the procedure. Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion. Care was taken to go from trigone to trigone. Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic. After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band. The suture band was lowered into position and tied in place. We then tested our repair and noted that there was very mild regurgitation. We subsequently removed our self-retaining retractor. We closed our left atriotomy using 4-0 Prolene in a running fashion. This was done without difficulty. We de-aired the heart. We then gave another round of antegrade and retrograde cardioplegia in warm fashion. The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity. We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene. We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin. The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed. We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula. This site was buttressed with a 4-0 Prolene on an SH needle. The patient tolerated the procedure well. We placed a mediastinal #32-French chest tube as well as a right chest Blake drain. The mediastinum was inspected for any signs of bleeding. There were none. We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion. The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
## 362 PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:, Basal Cell CA.,LOCATION: ,Medial right inferior helix.,PREOP SIZE:, 1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
## 363 PREOPERATIVE DIAGNOSES:,1. Partial rotator cuff tear with impingement syndrome.,2. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1. Partial rotator cuff tear with impingement syndrome.,2. Degenerative osteoarthritis of acromioclavicular joint, left shoulder.,PROCEDURE PERFORMED:,1. Arthroscopy with arthroscopic rotator cuff debridement.,2. Anterior acromioplasty.,3. Mumford procedure left shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operative Suite, Room #1 at ABCD General Hospital. This was done in a modified beach chair position with interscalene and subsequent general anesthetic.,HISTORY AND GROSS FINDINGS: , This is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention. He was refractory to conservative outpatient therapy. He had injection of his AC joint, which removed symptoms but was not long lasting. After discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side. All else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum. The remainder of the rotator cuff observed was noted to be intact. Subacromially, the patient was noted to have increased synovitis. Degenerative changes were noted upon observation of the distal clavicle.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table. After receiving interscalene block anesthetic by Anesthesia Department, the patient was placed in modified beach chair position. He was prepped and draped in the usual sterile manner. Portals were created posteriorly and anteriorly from outside to in. A full and complete diagnostic intraarticular arthroscopy was carried out. Debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff. Retrospectively it was approximately 25% of the generalized thickness.,Attention was then turned to the subacromial region. The scope was directed subacromially. A portal was created laterally. Ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle. Gross bursectomy was carried out with a 4.2 meniscal shaver. #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,It was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200. Because of this and difficulties with his anesthetic, it was elected to change to an open procedure. Thus, the patient was anesthetized safely and secured. An oblique incision was carried at the cross Langer's line across the outlet of the shoulder through the skin and subcutaneous tissue. Hemostasis was controlled via electrocoagulation. Flaps were created. Anterior deltoid was reflected inferiorly. Anterior acromioplasty was carried out with a saw then a Micro-Aire and then a beaver-tail rasp. An excellent decompression was present. CA ligament had been previously resected. We then took the incision over the distal clavicle. The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro-Aire saw. The beaver-tail rasp was utilized to smooth off the edges. Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted #1 Vicryl. Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same. A superficial running #2-0 Vicryl suture was utilized for deltoid closure distally. Interrupted #2-0 Vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and Adaptic, 4x4s, ABDs, and Elastoplast tape placed for compression dressing. 0.25% Marcaine was flooded into the joint prior to the skin closure. Pain buster catheter was hooked up. The patient's arm was placed in arm sling. He was safely transferred to the PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair.
## 364 PREOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,PROCEDURES:,1. Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago. Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions. She had requested a procedure to bring about further facial asymmetry. She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate. She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left. Preoperative workup including CT scan failed to show any skeletal trauma. The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:, The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake. General endotracheal anesthesia was induced with a #6 endotracheal tube. All appropriate measures were taken to preserve the vocal cords in a professional singer. Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia. The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine. Adequate time for vasoconstriction and anesthesia was allowed to be obtained. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture was placed in the right lower lid. For traction, it was brought anteriorly. The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe. A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone. The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present. The inferior oblique muscle was identified, preserved, and protected throughout the procedure. The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut. Contralateral side was treated in similar fashion with like results and throughout the procedure. Lacri-Lube was in the eyes in order to maintain hydration. Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds. Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia. A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane. Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle. The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle. It was bipolar electrocauteried and the tunnel was further dissected free and opened. The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection. The guard was removed and the suspension spikes were engaged into the soft tissues. The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally. The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture. Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained. The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples. The sterile dressing was applied. The patient was awakened in the operating room and taken to the recovery room in good condition.
## 365 PREOPERATIVE DIAGNOSIS: , Right profound mixed sensorineural conductive hearing loss.,POSTOPERATIVE DIAGNOSIS:, Right profound mixed sensorineural conductive hearing loss.,PROCEDURE PERFORMED:, Right middle ear exploration with a Goldenberg TORP reconstruction.,ANESTHESIA:, General ,ESTIMATED BLOOD LOSS:, Less than 5 cc.,COMPLICATIONS:, None.,DESCRIPTION OF FINDINGS:, The patient consented to revision surgery because of the profound hearing loss in her right ear. It was unclear from her previous operative records and CT scan as to whether or not she was a reconstruction candidate. She had reports of stapes fixation as well as otosclerosis on her CT scan.,At surgery, she was found to have a mobile malleus handle, but her stapes was fixed by otosclerosis. There was no incus. There was no specific round window niche. There was a very minute crevice; however, exploration of this area did not reveal a niche to a round window membrane. The patient had a type of TORP prosthesis, which had tilted off the footplate anteriorly underneath the malleus handle.,DESCRIPTION OF THE PROCEDURE:, The patient was brought to the operative room and placed in supine position. The right face, ear, and neck prepped with ***** alcohol solution. The right ear was draped in the sterile field. External auditory canal was injected with 1% Xylocaine with 1:50,000 epinephrine. A Fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o'clock to the 7 o'clock position. Meatal skin was elevated, middle ear was entered. This exposure included the oval window, round window areas. There was a good cartilage graft in place and incorporated into the posterior superior ***** of the drum. The previous prosthesis was found out of position as it had tilted out of position anteriorly, and there was no contact with the footplate. The prosthesis was removed without difficulty. The patient's stapes had an arch, but the ***** was atrophied. Malleus handle was mobile. The footplate was fixed. Consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion; however, upon inspection of the round window area, there was found to be no definable round window niche, no round window membrane. The patient was felt to have obliterated otosclerosis of this area along with the stapes fixation. She is not considered to be a reconstruction candidate under the current circumstances. No attempt was made to remove bone from the round window area. A different style of Goldenberg TORP was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate. The fit was secure and supported with Gelfoam in the middle ear. The tympanomeatal flap was returned to anatomic position supported with Gelfoam saturated Ciprodex. The incision was closed with #4-0 Vicryl and individual #5-0 nylon to the skin, and a sterile dressing was applied.
## 366 PREOPERATIVE DIAGNOSIS:, Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS:, Adenocarcinoma of the prostate.,TITLE OF OPERATION:, Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.,ANESTHESIA: , General by intubation.,Informed consent was obtained for the procedure. The patient understands the treatment options and wishes to proceed. He accepts the risks to include bleeding requiring transfusion, infection, sepsis, incontinence, impotence, bladder neck constricture, heart attack, stroke, pulmonary emboli, phlebitis, injury to the bladder, rectum, or ureter, etcetera.,OPERATIVE PROCEDURE IN DETAIL: , The patient was taken to the Operating Room and placed in the supine position, prepped with Betadine solution and draped in the usual sterile fashion. A 20- French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage. The table was then placed in minimal flexed position. A midline skin incision was then made from the umbilicus to the symphysis pubis. It was carried down to the anterior rectus fascia into the pelvis proper. Both obturator fossae were exposed. Standard bilateral pelvic lymph node dissections were carried out. The left side was approached first by myself. The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially, and from the bifurcation of the common iliac vein proximally to Cooper's ligament distally. Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2-0 silk ligatures. The obturator nerve was visualized throughout and was not injured. The right side was carried out by my assistant under my direct and constant supervision. Again, the obturator nerve was visualized throughout and it was not injured. Both packets were sent to Pathology where no evidence of carcinoma was found.,My attention was then directed to the prostate itself. The endopelvic fascia was opened bilaterally. Using gentle dissection with a Kitner, I swept the levator muscles off the prostate and exposed the apical portion of the prostate. A back bleeding control suture of 0 Vicryl was placed at the mid-prostate level. A sternal wire was then placed behind the dorsal vein complex which was sharply transected. The proximal and distal portions of this complex were then oversewn with 2-0 Vicryl in a running fashion. When I was satisfied that hemostasis was complete, my attention was then turned to the neurovascular bundles.,The urethra was then sharply transected and six sutures of 2-0 Monocryl placed at the 1, 3, 5, 7, 9 and 11 o'clock positions. The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers' fascia was incised distally, swept off the rectum and incorporated with the prostate specimen. The lateral pedicles over the seminal vesicles were then mobilized, hemoclipped and transected. The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips. Ampullae of the vas were mobilized, hemoclipped and transected. The bladder neck was then developed using careful blunt and sharp dissection. The prostate was then transected at the level of the bladder neck and sent for permanent specimen. The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge. The bladder neck was reconstructed in standard fashion. It was closed using a running 2-0 Vicryl. The mucosa was everted over the edge of the bladder neck using interrupted 3-0 Vicryl suture. At the end of this portion of the case, the new bladder neck had a stoma-like appearance and would accommodate easily my small finger. The field was then re-evaluated for hemostasis which was further obtained using hemoclips, Bovie apparatus and 3-0 chromic ligatures. When I was satisfied that hemostasis was complete, the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck. A new 20-French Foley catheter was brought in through the urethra into the bladder. A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant. The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated. The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight. The pelvis was also copiously irrigated with 2 liters of sterile water. A 10-French Jackson-Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2-0 silk ligature.,The wound was then closed in layers. The muscle was closed with a running 0 chromic, the fascia with a running 1-0 Vicryl, the subcutaneous tissue with 3-0 plain, and the skin with a running 4-0 Vicryl subcuticular. Steri-Strips were applied and a sterile dressing.,The patient was taken to the Recovery Room in good condition. There were no complications. Sponge and instrument counts were reported correct at the end of the case.
## 367 PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:, Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:, None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma. He was brought to the operating room now for Port-A-Cath placement for chemotherapy. After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position. After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted. Needle was removed. Small incision was made large enough to harbor the port. Dilator and introducers were then placed over the guidewire. Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers. Introducers were peeled away without difficulty. He measured with fluoroscopy and cut to the appropriate length. The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium. It was then connected to the hub of the port. Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall. Wounds were then closed. Needle count, sponge count, and instrument counts were all correct.
## 368 PREOPERATIVE DIAGNOSIS:, Rhabdomyosarcoma of the left orbit.,POSTOPERATIVE DIAGNOSIS:, Rhabdomyosarcoma of the left orbit.,PROCEDURE: , Left subclavian vein MediPort placement (7.5-French single-lumen).,INDICATIONS FOR PROCEDURE: , This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit. The patient is being taken to the operating room for MediPort placement. She needs chemotherapy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion. An incision was made on the left shoulder area. The left subclavian vein was cannulated. The wire was passed, which was in good position under fluoro, using Seldinger Technique. Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon. I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer. The line tip was in good position under fluoro. It withdrew and flushed well. I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips. Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush. We secured this with Tegaderm. The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.
## 369 PREOPERATIVE DIAGNOSIS:, Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1. Right thoracotomy.,2. Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:, Stable, extubated, to PACU.,PROCEDURE IN DETAIL:, Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm. He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma. Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm. He was explained the risks, benefits, and alternatives to this procedure. He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed. He was put in a supine position where SCDs and Foley catheter were placed. He was put under general endotracheal anesthesia with a double-lumen endotracheal tube. He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered. Upon entering the chest, the chest wall retractor was inserted and the cavity inspected. It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm. He also had some marked lymphadenopathy. With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection. Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly. We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe. The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties. Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment. This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk. This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe. This was also ligated in continuity and actually doubly ligated. Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein. The superior pulmonary vein was visualized as well. The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie. Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures. The bronchial anatomy was defined. Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe. A TA-30 4.8 stapler was then closed. The lung insufflated. The right middle lobe and right upper lobe were noted to inflate well. The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm. There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin. Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved. It seemed that it would be a mucoid shallow portion. The Bovie was set to high cautery. The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver. It did leave quite a shallow defect in the liver. Hemostasis was achieved with Bovie cautery and gentle pressure. The specimen was then taken off the table and sent to Pathology for permanent. The area was inspected for hemostasis. A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension. A single 32 straight chest tube was also placed. The lung was seen to expand. We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe. Hemostasis was observed at the end of the case. The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump. The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs. The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin. The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.
## 370 PREOPERATIVE DIAGNOSES:,1. Fullness in right base of the tongue.,2. Chronic right ear otalgia.,POSTOPERATIVE DIAGNOSIS: , Pending pathology.,PROCEDURE PERFORMED: , Microsuspension direct laryngoscopy with biopsy.,ANESTHESIA: , General.,INDICATION:, This is a 50-year-old female who presents to the office with a chief complaint of ear pain on the right side. Exact etiology of her ear pain had not been identified. A fiberoptic examination had been performed in the office. Upon examination, she was noted to have fullness in the right base of her tongue. She was counseled on the risks, benefits, and alternatives to surgery and consented to such.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Operative Suite where she was placed in supine position. General endotracheal tube intubation was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away where a shoulder roll was placed. A tooth guard was then placed to protect the upper dentition. The Dedo laryngoscope was then inserted into the oral cavity. It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view. At this point, it was advanced underneath the epiglottis until the vocal cords were seen. At this point, it was suspended via the Lewy suspension arm from the Mayo stand. At this point, the Zeiss microscope with a 400 mm lens was brought into the surgical field. Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities. It should be mentioned that the right vocal cord did appear to be slightly more hyperemic, however, there were no mucosal abnormalities identified. This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle. At this point, the scope was desuspended and the microscope was removed. The scope was withdrawn through the vallecular region. Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable. Biopsies were obtained with straight-biting cup forceps. Once hemostasis was achieved, the scope was advanced into the piriform sinuses. Again in the right piriform sinus, there was noted to be studding along the right lateral wall of the piriform sinus. Again, biopsies were performed and once hemostasis was achieved, the scope was further withdrawn down the lateral pharyngeal wall. There were no mucosal abnormalities identified within the oropharynx. The scope was then completely removed and a bimanual examination was performed. No neck masses were identified. At this point, the procedure was complete. The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident.
## 371 TITLE OF OPERATION: , Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,INDICATION FOR SURGERY: , The patient is a 37-year-old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04/07 with final pathology revealing extrafocal, extrathyroidal extension, and extranodal extension in the soft tissues of his medullary thyroid cancer. The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease. Fine-needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer. Risks, benefits, and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed. The risks included, but not limited to anesthesia, bleeding, infection, injury to nerve, lip, tongue, shoulder, weakness, tongue numbness, droopy eyelid, tumor comes back, need for additional treatment, diaphragm weakness, pneumothorax, need for chest tube, others. The patient understood all these issues and did wish to proceed.,PROCEDURE DETAIL: ,After identifying the patient, the patient was placed supine on the operating room table. The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube. The eyes were protected with Tegaderm. The patient was rotated to 180 degrees towards the operating surgeon. The Foley catheter was placed into the bladder with good return of urine. Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately. A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip. The incision then was planned around the old scar to be excised. A 1% lidocaine with 1 to 100,000 epinephrine was injected. A shoulder roll was applied. The incision was made, the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly. Attention was then turned to performing the level 1 dissection on the left. Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible. The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve. Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric. The submandibular gland was appreciated and retracted laterally. The mylohyoid muscle appreciated. The lingual nerve was appreciated and the submandibular ganglion was ligated. The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis. The marginal mandibular nerve stimulated at the completion of this portion of the procedure. Attention was then turned to incising the fascia along the clavicle on the left side. Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified. The brachial plexus and phrenic nerve were identified. The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels. Attention was then turned to the central neck. The strap muscles were appreciated in the midline. There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature. A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed. Attention was then turned to identify the carotid artery and the internal jugular vein on the left side. This was traced inferiorly, internal jugular vein to the brachiocephalic vein. Palpation deep to this area into the mediastinum and up against the trachea revealed a 1.5 cm lymph node mass. Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis. Attention was then turned to the right neck dissection. A posterior flap on the right was raised to the anterior border of the trapezius. The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly. Attention was then turned to identifying the submandibular gland. A digastric tunnel was performed back to the sternocleidomastoid muscle. The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated. The omohyoid muscle was retracted inferiorly. Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle. Subsequently the internal jugular vein was identified. The external jugular vein ligated about 1 cm above the clavicle. Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex. Dissection along the floor of the neck then was performed to allow for mobilization. The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass. Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated. The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly. The cervical rootlets were transected after the contribution, so the phrenic nerve all the way superiorly to the skull base. The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein. The wound was copiously irrigated. Valsalva maneuver was given. No bleeding points identified. The wound was then prepared for closure. Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3-0 nylon. The wound was closed with interrupted 3-0 Vicryl for platysma, subsequently a 4-0 running Biosyn for the skin, and Indermil. The patient tolerated the procedure well, was extubated on the operating room table, and sent to the postanesthesia care unit in good condition.
## 372 PREOPERATIVE DIAGNOSIS:, Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1. Medial meniscal tear, right knee.,2. Lateral meniscal tear, right knee.,3. Osteochondral lesion, medial femoral condyle, right knee.,4. Degenerative joint disease, right knee.,5. Patella grade-II chondromalacia.,6. Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1. Arthroscopy, right knee.,2. Medial meniscoplasty, right knee.,3. Lateral meniscoplasty, right knee.,4. Medial femoral chondroplasty, right knee.,5. Medical femoral microfracture, right knee.,6. Patellar chondroplasty.,7. Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice. The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:, The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position. Department of Anesthesia administered general anesthetic. Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder. Care was ensured that all bony prominences were well padded and she was positioned and secured. After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion. Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively. The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch. All compartments were then examined in sequential order with photodocumentation of each compartment. The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove. There was mild grooving of the trochlear cartilage. The medial gutter was visualized. There was no evidence of loose body. The medial compartment was then entered. There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment. There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus. The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken. At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed. This gave a smooth shoulder to the chondral lesion. After this, the meniscus was debrided until it had been smooth over the frayed edges. At this point, the shaver was removed. The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point. The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge. The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable. At this point, attention was directed to the rest of the knee. The ACL was examined. It was intact and stable. The lateral compartment was then entered. There was noted to be a grade II-III changes of the lateral femoral condyle. Again, with the edge of some friability at the shoulder of this cartilage lesion. There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus. The probe was introduced and the remaining meniscus appeared stable. This was then removed and the stapler was introduced. A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over. The lateral gutter was then visualized. There was no evidence of loose bodies. Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion. Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion. After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided. At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided. Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies. The knee was then copiously irrigated and suctioned dry. All instrumentation was removed. Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular. Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied. The patient was then transferred back to the gurney in supine position.,DISPOSITION: The patient tolerated the procedure well with no complications. The patient was transferred to PACU in satisfactory condition.
## 373 PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:, Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:, General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma. Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion. The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL: ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position. A double-lumen endotracheal tube was placed. SCDs were also placed and he was given preoperative Kefzol. The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion. A needle was inserted in the axillary line to determine position of the effusion. At this time, a 10-mm port was placed using the knife and Bovie cautery. The effusion was drained by placing a sucker into this port site. Upon feeling the surface of the pleura, there were multiple firm nodules. An additional anterior port was then placed in similar fashion. The effusion was then drained with a sucker. Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura. Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease. This will be worked up with further imaging study later in his hospitalization. After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc. The lungs were then inflated and noted to inflate well. A 32 curved chest tube chest tube was placed and secured with nylon. The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin. The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.
## 374 PREOPERATIVE DIAGNOSIS: ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS:, Metastatic renal cell carcinoma.,PROCEDURE PERFORMED:, Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy used to confirm adequate placement of the double-lumen endotracheal tube with a tube thoracostomy, which was used to drain the left chest after the procedure.,ANESTHESIA:, General endotracheal anesthesia with double-lumen endotracheal tube.,FINDINGS:, Multiple pleural surface seeding, many sub-millimeter suspicious looking lesions.,DISPOSITION OF SPECIMENS:,To Pathology for permanent analysis as well as tissue banking. The lesions sent for pathologic analysis were the following,,1. Level 8 lymph node.,2. Level 9 lymph node.,3. Wedge, left upper lobe apex, which was also sent to the tissue bank and possible multiple lesions within this wedge.,4. Wedge, left upper lobe posterior.,5. Wedge, left upper lobe anterior.,6. Wedge, left lower lobe superior segment.,7. Wedge, left lower lobe diaphragmatic surface, anterolateral.,8. Wedge, left lower lobe, anterolateral.,9. Wedge, left lower lobe lateral adjacent to fissure.,10. Wedge, left upper lobe, apex anterior.,11. Lymph node package, additional level 8 lymph node.,ESTIMATED BLOOD LOSS:, Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE: , The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into. The patient agreed based on the risks and the benefits of the procedure, which were presented to him and was taken to the operating room. A correct time out procedure was performed. The patient was placed into the supine position. He was given general anesthesia, was endotracheally intubated without incident with a double-lumen endotracheal tube. Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double-lumen tube. Following this, the decision was made to proceed with the surgery. The patient was rolled into the right lateral decubitus position with the left side up. All pressure points were padded. The patient had a sterile DuraPrep preparation to the left chest. A sterile drape around that was applied. Also, the patient had Marcaine infused into the incision area. Following this, the patient had a posterolateral thoracotomy incision, which was a muscle-sparing incision with a posterior approach just over the ausculatory triangle. The incision was approximately 10 cm in size. This was created with a 10-blade scalpel. Bovie electrocautery was used to dissect the subcutaneous tissues. The auscultatory triangle was opened. The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly. The muscle was not divided. After the latissimus muscle was retracted anteriorly, the ribs were counted, and the sixth rib was identified. The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears. Following this, the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach. The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions, which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges. The patient tolerated the procedure well without any complications. The largest lesion was the left upper lobe apex lesion, which was possibly multiple lesions, which was taken in one large wedge segment, and this was also adjacent to another area of the wedges. The patient had multiple pleural abnormalities, which were identified on the surface of the lung. These were small white spotty looking lesions and were not confirmed to be tumor implants, but were suspicious to be multiple areas of tumor. Based on this, the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions. Following this, the patient had a 32-French chest tube placed in the anteroapical position. A 19-French Blake was placed in the posterior apical position. The patient had the intercostal space reapproximated with #2-0 Vicryl suture, and the lung was allowed to be re-expanded under direct visualization. Following this, the chest tubes were placed to Pleur-evac suction and the auscultatory triangle was closed with 2-0 Vicryl sutures. The deeper tissue was closed with 3-0 Vicryl suture, and the skin was closed with running 4-0 Monocryl suture in a subcuticular fashion. The patient tolerated the procedure well and had no complications.
## 375 PREOPERATIVE DIAGNOSIS:, Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:, Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE: ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.
## 376 PREOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago. He had epicardial pacing wires removed at the bedside. Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic. He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires. He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE: ,The patient was taken emergently to the operating room and placed supine on the operating room table. His chest was prepped and draped prior to induction under general anesthesia. Incision was made through the previous median sternotomy chest incision. Wires were removed in the usual manner and the sternum was retracted. There were large amounts of dark blood filling the mediastinal chest cavity. Large amounts of clot were also removed from the pericardial well and chest. Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation. This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures. An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis. No other sites of bleeding were identified. The mediastinum was then irrigated with copious amounts of antibiotic saline solution. Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube. The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures. The skin was then closed with a running subcuticular stitch. The patient was then taken to the Intensive Care Unit in a critical but stable condition.
## 377 TITLE OF OPERATION:, Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:, The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass. The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago. She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma. At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position. Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed. The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed. The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned. Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy. The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires. The subcutaneous tissue and skin were closed in layers. There was no evidence of significant increase in central venous pressure or desaturation. The patient tolerated the procedure well. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case.
## 378 PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure. Oxygenation was given. The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE: ,The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine. The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***. Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen. Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves. Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts. Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue. After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds. All injected medications were preservative free. Sterile technique was used throughout the procedure.,COMPLICATIONS:, None. No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.
## 379 PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY: ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot. The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes. The patient has requested surgical intervention at this time.,PROCEDURE: ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room. The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table. Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle. Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot. After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner. Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg. The foot was then brought back down to the table using bandage scissors. The stockinette was reflected and the right foot was exposed. Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot. Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted. Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified. Further dissection was then performed in the medial direction in the area of the soft tissue mass. The intermediate dorsal cutaneous nerve was identified and gently retracted laterally. Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle. Using careful dissection, adipose tissue in this area was removed and saved for pathology. Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well. Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology. There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well. Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline. The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue. The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact. No deficits were noted. No abnormal appearing tissue was present within the surgical site. Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed. Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders. The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia. Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban. The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot. The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact. The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe. The patient was then given postoperative instructions to include ice and elevation to her right foot. The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain. The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up. The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days. The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these. The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit.
## 380 OPERATIVE NOTE: ,The patient was taken to the operating room and was placed in the supine position on the operating room table. A general inhalation anesthetic was administered. The patient was prepped and draped in the usual sterile fashion. The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated. Next a midline ventral type incision was made opening the meatus. This was done after clamping the tissue to control bleeding. The meatus was opened for about 3 mm. Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds. Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures. The meatus still calibrated between 10 and 12 French. Antibiotic ointment was applied. The procedure was terminated. The patient was awakened and returned to the recovery room in stable condition.
## 381 HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital. He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,POSTOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,PROCEDURE: , Closed reduction of mandible fractures with Erich arch bars and elastic fixation.,ANESTHESIA:, General nasotracheal.,COMPLICATIONS:, None.,CONDITION:, Stable to PACU.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars. Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires. After the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable. The throat pack was then removed. An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out.,The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the PACU in stable condition.
## 382 PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder. Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle.,PROCEDURE,With the patient under satisfactory general endotracheal anesthesia, the entire chest was prepped and draped in usual sterile fashion. A previously placed mark to identify the neo-nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory. A keyhole wire ring was then used to outline the basic wise pattern with 6-cm lamps inferiorly. This was then carefully checked for symmetry and appeared to be satisfactory. All marks were then completed and lightly incised on both breasts. The right breast was approached first. The neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelialized using cutting cautery. After this had been completed, cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately. This was taken down to the prepectoral fashion dissected for short distance superiorly, and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle. There was very little bleeding with this procedure. After this had been completed, attention was directed to the lateral side, and the inferior incision was made and taken down to the serratus. Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket. After this had been completed, cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast. Hemostasis was obtained with electrocautery. After this had been completed, cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps. On the right side, there was a small palpable lobule, which had shown up on mammogram, but nothing except some fat density was identified. This site had been previously marked carefully, and there were no unusual findings and the superior tissue was then sent out separately for pathology. After this had been completed, final hemostasis obtained, and the wound was irrigated and a tagging suture placed to approximate the tissues. The breast cleared and the nipple appeared good.,Attention was then directed to the left breast, which was completed in the similar manner. After this had been completed, the patient was placed in a near upright position, and symmetry appeared good, but it was a bit poor on the lateral aspect of the right side, which was little larger and some suction lipectomy was carried out in this area. After completion of this, 1860 grams had been removed from the right and 1505 grams was removed from the left. Through separate stab wounds on the lateral aspect, 10-mm flat Blake drains were brought out and sutures were then placed **** and irrigated. The wounds were then closed with interrupted 4-0 Monocryl on the deep dermis and running intradermal 4-0 Monocryl on the skin, packing sutures and staples were removed as they were approached. The nipple was sutured with running intradermal 4-0 Monocryl. Vascularity appeared good throughout. After this had been completed, all wounds were cleaned and Steri-Stripped. The patient tolerated the procedure well. All counts were correct. Estimated blood loss was less than 150 mL, and she was sent to recovery room in good condition.
## 383 OPERATIVE NOTE: ,The patient was placed in the supine position under general anesthesia, and prepped and draped in the usual manner. The penis was inspected. The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove. This was incised longitudinally and closed transversely with 5-0 chromic catgut sutures. The meatus was calibrated and accepted the calibrating instrument without difficulty, and there was no stenosis. An incision was made transversely below the meatus in a circumferential way around the shaft of the penis, bringing up the skin of the penis from the corpora. The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie. Using a skin hook, the meatus was elevated ventrally and the glans flaps were reapproximated using 5-0 chromic catgut, creating a new ventral portion of the glans using the flaps of skin. There was good viability of the skin. The incision around the base of the penis was performed, separating the foreskin that was going to be removed from the coronal skin. This was removed and hemostasis was obtained with a Bovie. 0.25% Marcaine was infiltrated at the base of the penis for post-op pain relief, and the coronal and penile skin was reanastomosed using 4-0 chromic catgut. At the conclusion of the procedure, Vaseline gauze was wrapped around the penis. There was good hemostasis and the patient was sent to the recovery room in stable condition.
## 384 PREOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1. Right McBride bunionectomy.,2. Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position. The right foot was prepared and draped in usual sterile manner. Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint. Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg. At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made. The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure. The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection. Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp. At this time, attention was directed to the first inner space using sharp and blunt dissection. Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments. The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment. At this time, the lateral release was stressed and was found to be complete. The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw. The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted. At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length. The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption. At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint. At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge. The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm. The screw was placed following proper technique. The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing. A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy. The packing of the cancellous bone was held in place with bone wax. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed. At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion. The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site. At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily. The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion. The tourniquet was dropped and color and temperature of all digits returned to normal. The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided. The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,
## 385 PREOPERATIVE DIAGNOSES:, Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,POSTOPERATIVE DIAGNOSES:, Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,OPERATION:, Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex with resection of 947 g in the larger right breast and 758 g in the smaller left breast.,ANESTHESIA: ,General endotracheal anesthesia.,PROCEDURE IN DETAIL: ,The patient was placed in the supine position under the effects of general endotracheal anesthesia. The breasts were prepped and draped with DuraPrep and iodine solution and then draped in appropriate sterile fashion. Markings were then made in the standing position preoperatively. The nipple areolar complex was drawn at the level of the anterior projection of the inframammary fold along the central margin of the breast. A McKissock ring was utilized as a pattern. It was centered over the new nipple position and the medial and lateral flaps were drawn tangential to the pigmented areola at a 40-degree angle. Medial and lateral flaps were drawn 8 cm in length. At the most medial and lateral extremity inframammary folds, a line was drawn to the lower level at the medial and lateral flaps. On the left side, the epithelialization was performed about the 45-mm nipple-areolar complex within the confines of the superior-medially based dermal parenchymal pedicle. Resection of the skin, subcutaneous tissue, and glandular tissue was performed along the inframammary fold, and then cut was made medially and laterally. The resection medially was perpendicular to the chest wall down to the areolar tissue overlying the pectoralis major muscle, and laterally, the resection was performed tangential to the chest wall, skin, subcutaneous tissue, and glandular tissue towards the axillary tail. The pedicle was thinned as well, so it was 2-cm thick beneath the nipple-areolar complex and they were medially 4-cm thick at its base. On the right side, 947 g of breast tissue was removed. Hemostasis was achieved with electrocautery. Identical procedure was performed on the opposite left side, again with a superiorly and inferiorly based dermal parenchymal pedicle with deepithelialization about the 45-mm diameter nipple-areolar complex. Resection of the skin, subcutaneous tissue, and glandular tissue was performed medially down to the chest overlying the pectoralis major muscle and laterally tangential to the chest wall towards the axillary tail setting the pedicle as well beneath the nipple areolar complex. Hemostasis was achieved with electrocautery. With pedicle on the left, the breast issue on the left side was weighed at 758 g. Hemostasis was achieved with cautery. The patient was placed in the sitting position with wound partially closed and there appeared to be excellent symmetry between the right and left sides. The nipple-areolar complex was transposed within the position and the medial and lateral flaps were brought together beneath the transposed nipple-areolar complex. Closure was performed with interrupted 3-0 PDS suture for deep subcutaneous tissue and dermis. Skin was closed with running subcuticular 4-0 Monocryl suture. A Jackson-Pratt drain had been placed prior to final closure and secured with a 4-0 silk suture. The wound had been irrigated prior to final closure as well with bacitracin irrigation solution prior to final cauterization. Closure was performed with an anchor-shaped closure around the nipple-areolar complex, vertically of inframammary folds and across the inframammary folds. Dressing was applied. The suture line was treated with Dermabond. The patient returned to the recovery room with 2 Jackson-Pratt drains, 1 on each side and IV Foley catheter with instructions to be seen in my office in 2 days. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
## 386 PREOPERATIVE DIAGNOSES,Breast hypoplasia, melasma to the face, and varicose veins to the posterior aspect of the right distal thigh/popliteal fossa area.,PROCEDURES,1. Bilateral augmentation mammoplasty, subglandular with a mammary gel silicone breast implant, 435 cc each.,2. TCA peel to two lesions of the face and vein stripping to the right posterior thigh and popliteal fossa area.,ANESTHESIA,General endotracheal.,EBL,100 cc.,IV FLUIDS,2L.,URINE OUTPUT,Per Anesthesia.,INDICATION FOR SURGERY,The patient is a 48-year-old female who was seen in clinic by Dr. W and where she was evaluated for her small breasts as well as dark areas on her face and varicose veins to the back and posterior aspect of her right lower extremity. She requested that surgical procedures to be performed for correction of these abnormalities. As such, complications were explained to the patient including infection, bleeding, poor wound healing, and need for additional surgery. The patient subsequently signed the consent and requested that Dr. W and associates to perform the procedure.,TECHNIQUE,The patient was brought to the operating room in supine position. General anesthesia was induced and then the patient was placed on the operating table in a prone position. The posterior thigh of the right lower extremity was prepped and draped in a sterile fashion. First, multiple serial small incisions less than 1 cm in length were made to the posterior aspect of the right thigh and sequential stripping of the varicose veins was performed. Once these varicose veins had been completely stripped and avulsed, then next the wounds were then irrigated and were cleaned with wet and dry, and all the incisions were closed with the use of 5-0 Monocryl buried interrupted sutures. The incisions were then dressed with Mastisol, Steri-Strips, ABDs and a TED hose. Next, the patient was then flipped back over onto the stretcher and placed on the operating table in a supine position. The anterior chest was then prepped and draped in a sterile fashion. Next, a 10 blade was placed through previous circumareolar incisions from a previous augmentation mammoplasty. Dissection was carried out with a 10 blade and Bovie cautery until the pectoralis fascia was identified to both breasts. Once the pectoralis muscle and fascia were identified, then a surgical plane was created in a subglandular layer. The hemostasis was obtained to both breast pockets with the Bovie cautery and suction and irrigation was performed to bilateral breast pockets as well. A sizer was used to identify the appropriate size of the silicone implant to be used. This was determined to be approximately 435 cc bilaterally. As such, two mammary gel silicone breast implants were placed in a subglandular muscle. Additional dissection of the breast pockets were performed bilaterally and the patient was sequentially placed in the upright sitting position for evaluation of appropriate placement of the mammary gel silicone implants. Once it was determined that the implants were appropriately selected and placed with the 435 cc silicon gel implant, the circumareolar incisions were closed in approximately 4-layered fashion closing the fascia, subcutaneous tissue, deep dermis, and a running dermal subcuticular for final skin closure. This was performed with 3-0 Monocryl and then 4-0 Monocryl for running subcuticular. The incisions were then dressed with Mastisol, Steri-Strips, and Xeroform and dressed with sample Kerlix. Next, our attention was paid to the face where 25% TCA solution was applied to two locations; one on the left cheek and the other one on the right cheek, where a hyperpigmentation/melasma. Several applications of the TCA peel was performed, and at the end of this, the frosting was noted to both spots. At the end of the case, needle and instrument counts were correct. Dr. W was present and scrubbed for the entire procedure. The patient was extubated in the operating room and taken to the PACU in stable condition.
## 387 DIAGNOSIS: , Bilateral hypomastia.,NAME OF OPERATION:, Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,ANESTHESIA:, General.,PROCEDURE: , After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and solution. Sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts. Following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5% Xylocaine with 1:200,000 units of epinephrine.,After a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia. Blunt dissection was then used to form a bilateral subpectoral pocket. Through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.,Following completion of irrigation, 350-cc saline-filled implants were introduced. They were first filled with 60 cc of saline and checked for gross leakage; none was evident. They were over filled to 400 cc of saline each. The patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.,Following completion of the filling of the implants and checking the breasts for symmetry, the patient's wounds were closed with interrupted vertical mattress sutures of 4-0 Prolene. Flexan dressings were applied followed by the patient's bra.,She seemed to tolerate the procedure well.
## 388 PREOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,POSTOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,PROCEDURE PERFORMED: ,Lysis of pelvic adhesions.,ANESTHESIA: , General with local.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: , The patient is a 32-year-old female who had an 8 cm left ovarian mass, which was evaluated by Dr. X. She had a ultrasound, which demonstrated the same. The mass was palpable on physical examination and was tender. She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy. During the surgery, there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon. These adhesions were taken down sharply with Metzenbaum scissors.,PROCEDURE: , A pelvic laparotomy had been performed by Dr. X. Upon exploration of the abdomen, multiple pelvic adhesions were noted as previously stated. A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery. These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst. The ureter had been identified and isolated prior to the adhesiolysis. There was no evidence of bleeding. The remainder of the case was performed by Dr. X and this will be found in a separate operative report.
## 389 PREOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,POSTOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,PROCEDURES PERFORMED,1. Sentinel lymph node biopsy.,2. Ultrasound-guided lumpectomy with intraoperative ultrasound.,ANESTHESIA,General LMA anesthesia.,ESTIMATED BLOOD LOSS,Minimum.,IV FLUIDS,Per anesthesia record.,COMPLICATIONS,None.,FINDINGS,Clip well localized within the specimen.,INDICATION,This is a 65-year-old female who presents with abnormal mammogram who underwent stereotactic biopsy at an outside facility, which showed atypical ductal hyperplasia with central necrosis. On reviewing this pathology, it is mostly likely DCIS. The risks and benefits of the procedure were explained to the patient who appeared to understand and agreed to proceed. The patient desired MammoSite Radiation Therapy; therefore, the sentinel lymph node biopsy was incorporated into the procedure.,PROCEDURE IN DETAIL,The patient was taken to the operating room, placed in supine position, and general LMA anesthesia was administered. She was prepped and draped in the usual sterile fashion. Prior to the procedure, she underwent nuclear medicine injection with technetium-99 and methylene blue. Incision was made of the area of great uptake and the axilla and taken through the subcutaneous tissue with electric Bovie cautery. Two sentinel lymph nodes were identified, one was blue and hot and the other was just hot. These were sent to Pathology for touch prep. Adequate hemostasis was obtained. The wound was packed and attention was turned to the left breast. Ultrasound was used to identify the marker and the mass within the breast and create an adequate anterior skin flap. An elliptical incision was made roughly at approximately the 3 o'clock position secondary to subcutaneous tissues with electric Bovie cautery. The mass was dissected off the surrounding tissue using Bovie cautery down to the level of the pectoralis fascia, which was incorporated within the specimen. The specimen was completely removed and marked **** double deep, and a mini C-arm was used to confirm this. The marker was well localized within the center of the specimen. The fascia was then elevated off of the pectoralis muscle and closed loosely with the interrupted 2-0 Vicryl sutures to create a nice spherical cavity for the MammoSite radiation catheter. The wound was then closed with a deep layer of interrupted 3-0 Vicryl followed by 3-0 Vicryl subcuticular stitch and 4-0 running Monocryl. The axillary wound was closed with interrupted 3-0 Vicryl and a running 4-0 Monocryl. Steri-Strips were applied. The patient was awakened and extubated in the OR and taken to PACU in stable condition. All counts were reported as correct. I was present for the entire procedure.
## 390 PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition.
## 391 PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1. Lumbar discogram L2-3.,2. Lumbar discogram L3-4.,3. Lumbar discogram L4-5.,4. Lumbar discogram L5-S1.,ANESTHESIA: ,IV sedation.,PROCEDURE IN DETAIL: ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table. The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained. We then proceeded to prepare the low back with a Betadine solution and draped sterile. Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space. A metallic marker was then placed laterally and a needle entrance point was determined. A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections. A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus. We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.
## 392 PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks, benefits, potential complications, as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created, the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.
## 393 REASON FOR VISIT: ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:, The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak. She has not been having any headaches. She has had a significant decrease in appetite. She is known to have lung cancer, but Ms. Wilson does not know what kind. According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung. The last note I have to evaluate is from October 2008. CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion. I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand. She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:, Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS: ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED: ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE: ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter. The patient' daughter remained present throughout the procedure. The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture. During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort. The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table. Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT: ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.
## 394 PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE: ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2. She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain. Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area. There was no evidence of infection on the imaging or with her laboratory studies. In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well. She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. She was placed on the operative table in the prone position. Back was prepared with Betadine, iodine, and alcohol. We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum. The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it. After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase. We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic. This was a combination of scar and overgrown bone. She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels. After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels. We used 10 x 32 mm spacers at both L4-L5 and L5-S1. This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3. This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level. Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well. The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin. Prior to closing the skin, we confirmed correct sponge and needle count. We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies. The Cell Saver blood was recycled and she was given two units of packed red blood cells as well. I was present for and performed the entire procedure myself or supervised.
## 395 PROCEDURE PERFORMED:, Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form. Alternatives were explained. They agreed to proceed with the lumbar puncture. Permit was signed and is on the chart. The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion. Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:, None. The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact. Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.
## 396 PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1. Injection for myelogram.,2. Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:, Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:, Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution. The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. He denied any previous history of back pain or back surgeries. Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on. After an informed consent was obtained, all risks as well as complications were discussed with the patient. ,PROCEDURE DETAIL: ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03. After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table. All of his bony prominences were well-padded. At this time, a myelogram was then performed. After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram. The needle was localized to the level of L3-L4 region. Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle. At this time, approximately 10 cc of Conray injected into the thecal sac. The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast. The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left. There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy. At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy. A long spinal needle was then inserted into region of surgery on the right. The surgery was going to be on the left. Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region. At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia. At this time, a Weitlaner was inserted. Bovie cautery was used to obtain hemostasis. We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina. A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side. At this time, a Taylor retractor was then inserted and held there for retraction. Suction as well as Bovie cautery was used to obtain hemostasis. At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression. Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots. Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive. We removed the extruded disc with further freeing up of the S1 nerve root. A nerve root retractor was then placed. Identification of disc space was then performed. A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade. A small pituitary was then inserted within the disc space and more disc material was freed and removed. The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc. Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound. We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur. At this time, a small piece of Gelfoam was then used to cover the exposed nerve root. We did not have any dural leaks during this case. #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin. Sterile dressings were then applied. The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition. At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.
## 397 PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test. She was transfused with packed red blood cells. Her hemolysis seemed to slow down. She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen. Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital. She had a blood culture, which was also negative. She was empirically started on presentation with the cefotaxime intravenously. Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics. After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present. She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures. The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression. Questions were answered to their satisfaction. They would like to proceed.,PROCEDURE IN DETAIL: , After "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained. She was then given Versed 1 mg intravenously by myself. She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied. She was then given 20 mcg of fentanyl intravenously by myself. She was placed in the left lateral decubitus position. Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution. She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision. Clear fluid was not obtained initially, needle was withdrawn intact. The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained. The stylette was replaced and the needle was withdrawn intact and bandage was applied. Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable. Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.
## 398 PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:, Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1. Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2. Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:, The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating. She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1. Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room. She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy. The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted. She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained. She was rolled in a prone position on the Wilson frame. The back was prepared in the usual manner with Betadine soak, followed by Betadine paint. Markings were applied. Sterile drapes were applied. Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1. Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes. A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1. The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1. Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3. A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5. Then using various Kerrison punches, I proceeded to perform a laminectomy. Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura. There was CSF leak. The lamina removal was continued, ligamentum flavum was removed to expose all the dura. Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula. There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1. Foraminotomies were accomplished bilaterally. The caudal aspect of the lamina of L3 also was removed. The dura came up quite nicely. I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free. Further more, the thecal sac came up quite nicely. In order to ensure no CSF leak, we would follow the patient out of the operating room. The dural closure was covered with a small piece of fat. This was all then covered with DuraSeal glue. Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond. The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion. Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon. The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS: Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS: Correct.,FINDINGS: A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1. There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.
## 399 PREOPERATIVE DIAGNOSES:,1. Extruded herniated disc, left L5-S1.,2. Left S1 radiculopathy (acute).,3. Morbid obesity.,POSTOPERATIVE DIAGNOSES:,1. Extruded herniated disc, left L5-S1.,2. Left S1 radiculopathy (acute).,3. Morbid obesity.,PROCEDURE PERFORMED: , Microscopic lumbar discectomy, left L5-S1.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,50 cc.,HISTORY: , This is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at L5-S1. She has been dealing with these symptoms for greater than three months. She comes to my office with severe pain, left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery. I have discussed the MRI findings with the patient and the potential risks and complications. She was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the Emergency Room. We discussed the diagnosis and the operative procedure in detail. I have reviewed the potential risks and complications and she had agreed to proceed with the surgery. Due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and I have discussed this with her. She is aware that she will have a much larger incision than what is standard and has agreed to accept this.,OPERATIVE PROCEDURE: ,The patient was taken to OR #5 at ABCD General Hospital. While in the hospital gurney, Department of Anesthesia administered general anesthetic, endotracheal intubation was followed. A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing. The table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb. Once the table was reinforced, the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded. A marker was placed in from the back at this time and an x-ray was obtained for incision localization. The back is now prepped and draped in the usual sterile fashion. A midline incision was made over the L5-S1 disc space taking through subcutaneous tissue sharply with a #10 Bard-Parker scalpel. The lumbar dorsal fascia was then encountered and incised to the left of midline. In the subperiosteal fashion, the musculature was elevated off the lamina at L5 and S1 after facet joint, but not disturbing the capsule. A second marker was now placed and an intraoperative x-ray confirms our location at the L5-S1 disc space. The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination. A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina. Ligaments and fragments were encountered and removed at this time. The epidural space was now encountered. The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield. A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening. This disc fragment was removed and the nerve root was much more supple, it was carefully retracted. The nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of S1 and L5. At this point, all disc fragments were removed from the epidural space. Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify. The disc space was now encountered and loose disc fragments were removed from within the disc space. The disc space was then irrigated. The nerve root was then reassessed and found to be quite supple. At this point, the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device. At this point, the wound was irrigated copiously and suctioned dry. Gelfoam was used to cover the epidural space. The retractors were removed at this point. The fascia was reapproximated with #1 Vicryl suture, subcutaneous tissue with #2-0 Vicryl suture and Steri-Strips for curved incision. The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia, subsequently transferred to Postanesthesia Care Unit in stable condition.
## 400 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 30 and 4/7th weeks.,2. Previous cesarean section x2.,3. Multiparity.,4. Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1. Intrauterine pregnancy at 30 and 4/7th weeks.,2. Previous cesarean section x2.,3. Multiparity.,4. Request for permanent sterilization.,5. Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1. Repeat low transverse cesarean section.,2. Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:, 200 cc of crystalloids.,URINE OUTPUT:, 300 cc of clear urine at the end of the procedure.,FINDINGS:, Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia. There were bowel adhesions noted through the anterior abdominal wall. The uterus was noted to be within normal limits. The tubes and ovaries bilaterally were noted to be within normal limits. The baby was delivered from the right sacral anterior position without any difficulty. Apgars 8 and 9. Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE: ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2. She had her first C-section because of congenial hip problems. In her second C-section, baby was breached, therefore, she is scheduled for a third C-section. The patient also requests sterilization. Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty. She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife. The fascia was excised in the midline extended laterally with the Mayo scissors. The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors. There was noted dense adhesions at this point as well as a wire mesh was noted. The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly. The rectus muscle superiorly was opened with a hemostat. The peritoneum was identified and entered bluntly digitally. The peritoneal incision was then extended superiorly up to the level of the mesh. Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder. The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally. The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors. The amniotic fluid was noted to be clear. At this point, upon examining the intrauterine contents, the baby was noted to be breached. The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty. The cord was clamped and the baby was then handed off to awaiting pediatricians. The placenta cord gases were obtained and the placenta was then manually extracted from the uterus. The uterus was exteriorized and cleared of all clots and debris. Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer. Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp. The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors. The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down. Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review. The uterus was then replaced back into the abdomen. The gutters were cleared of all clots and debris. The uterine incision was then once again inspected and noted to be hemostatic. The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures. The peritoneum was then closed with #3-0 Vicryl in a running fashion. Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion. The fascia was then closed with #0 Vicryl in a running fashion. The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl. Then, the skin edges were reapproximated using sterile clips. The dressing was placed. The uterus was then cleared of all clots and debris manually. Then, the patient tolerated the procedure well. Sponge, lap, and needle, counts were correct x2. The patient was taken to recovery in sable condition. She will be followed up throughout her hospital stay.
## 401 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 38 weeks.,2. Malpresentation.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 38 weeks.,2. Malpresentation.,3. Delivery of a viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,ANESTHESIA: , Spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 300 cc.,URINE OUTPUT:, 80 cc of clear urine.,FLUIDS: , 2000 cc of crystalloids.,COMPLICATIONS: , None.,FINDINGS: , A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g. No nuchal cord. No meconium. Normal uterus, fallopian tubes, and ovaries.,INDICATIONS: , This patient is a 21-year-old gravida 3, para 1-0-1-1 Caucasian female who presented to Labor and Delivery in labor. Her cervix did make some cervical chains. She did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head. However, on exam unable to delineate the facial structures, but definite fetal malpresentation. The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring. The contraction pattern was inadequate. It was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended. All the questions were answered.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt. Prior to this, the spinal anesthesia was administered. The patient was then prepped and draped. A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel. The fascia was then incised in the midline and extended laterally using Mayo scissors. The superior aspect of the rectus fascia was then grasped with Ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors. The superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors. The rectus muscle was then separated in the midline. The peritoneum was then identified, tented up with hemostats and entered sharply with Metzenbaum scissors. The peritoneum was then gently stretched. The vesicouterine peritoneum was then identified, tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors. The uterus was entered with the second scalpel and large transverse incision. This was then extended in upward and lateral fashion bluntly. The infant was then delivered atraumatically. The nose and mouth were suctioned. The cord was then clamped and cut. The infant was handed off to the awaiting pediatrician. The placenta was then manually extracted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was then repaired using #0 chromic in a running fashion marking a U stitch. A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis. The uterus was then returned to the anatomical position. The abdomen and the gutters were cleared of all clots. Again, the incision was found to be hemostatic. The rectus muscle was then reapproximated with #2-0 Vicryl in a single interrupted stitch. The rectus fascia was then repaired with #0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion. This was palpated and the patient was found to be without defect and intact. The skin was then closed with staples. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. She will be followed up as an inpatient with Dr. X.
## 402 PREOPERATIVE DIAGNOSES,1. Intrauterine pregnancy at 35-1/7.,2. Rh isoimmunization.,3. Suspected fetal anemia.,4. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES,1. Intrauterine pregnancy at 35-1/7.,2. Rh isoimmunization.,3. Suspected fetal anemia.,4. Desires permanent sterilization.,OPERATION PERFORMED: , Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.,ANESTHESIA:, Spinal anesthesia.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,500 mL.,INTRAOPERATIVE FLUIDS: , 1000 mL crystalloids.,URINE OUTPUT: , 300 mL clear urine at the end of procedure.,SPECIMENS:, Cord gases, hematocrit on cord blood, placenta, and bilateral tubal segments.,INTRAOPERATIVE FINDINGS: , Male infant, vertex position, very bright yellow amniotic fluid. Apgars 7 and 8 at 1 and 5 minutes respectively. Weight pending at this time. His name is Kasson as well as umbilical cord and placenta stained yellow. Otherwise normal appearing uterus and bilateral tubes and ovaries.,DESCRIPTION OF OPERATION:, After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was obtained by Dr. X without difficulties. The patient was placed in supine position with leftward tilt. Fetal heart tones were checked and were 140s, and she was prepped and draped in a normal sterile fashion. At this time, a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery. The fascia was nicked sharply in the midline. The fascial incision was extended laterally with Mayo scissors. The inferior aspect of the fascial incision was grasped with Kocher x2, elevated, and rectus muscles dissected sharply with the use of Mayo scissors. Attention was then turned to the superior aspect of the fascial incision. Fascia was grasped, elevated, and rectus muscles dissected off sharply. The rectus muscles were separated in the midline bluntly. The peritoneum was identified, grasped, and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder. Bladder blade was inserted. Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors. Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U-shaped fashion with the scalpel. Uterine incision was extended laterally and manually. Membranes were ruptured and bright yellow clear amniotic fluid was noted. Infant's head was in a floating position, able to flex the head, push against the incision, and then easily brought it to the field vertex. Nares and mouth were suctioned with bulb suction. Remainder of the infant was delivered atraumatically. The infant was very pale upon delivery. Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team. An 8 cm segment of the tube was doubly clamped and transected. Cord gases were obtained. Cord was then cleansed, laid on a clean laparotomy sponge, and cord blood was drawn for hematocrit measurements. At this time, it was noted that the cord was significantly yellow stained as well as the placenta. At this time, the placenta was delivered via gentle traction on the cord and exterior uterine massage. Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1-0 chromic in a running locked fashion. Two areas of oozing were noted and separate figure-of-eight sutures were placed to obtain hemostasis. At this time, the uterine incision was hemostatic. The bladder was examined and found to be well below the level of the incision repair. Tubes and ovaries were examined and found to be normal. The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp. Mesosalpinx was divided with electrocautery and a 4-cm segment of tube was doubly tied and transected with a 3-cm segment of tube removed. Hemostasis was noted. Then, attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp. Mesosalpinx was incised and 3-4 cm tube doubly tied, transected, and excised and excellent hemostasis was noted. Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen. Gutters were cleared off all clots and debris. Lower uterine segments were again re-inspected and found to be hemostatic. Sites of tubal sterilization were also visualized and were hemostatic. At this time, the peritoneum was grasped with Kelly clamps x3 and closed with running 3-0 Vicryl suture. Copious irrigation was used. Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline. At this time, the fascia was closed using 0 Vicryl in a running fashion. Manual palpation confirms thorough and adequate closure of the fascial layer. Copious irrigation was again used. Hemostasis noted, and skin was closed with staples. The patient tolerated the procedure well. Sponge, lap, needle, and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition. Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia. The patient will be followed for her severe right upper quadrant pain post delivery. If she continues to have pain, may need a surgical consult for gallbladder and/or angiogram for evaluation of right kidney and questionable venous plexus. This all will be relayed to Dr. Y, her primary obstetrician who was on call starting this morning at 7 a.m. through the weekend.
## 403 PREOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,OPERATION:, Primary low-transverse C-section.,ANESTHESIA:, Epidural.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room and under epidural anesthesia, she was prepped and draped in the usual manner. Anesthesia was tested and found to be adequate. Incision was made, Pfannenstiel, approximately 1.5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty; the fascia being incised laterally. Bleeders were bovied. Rectus muscles were separated from the overlying fascia with blunt and sharp dissection. Muscles were separated in the midline. Peritoneum was entered sharply and incision was carried out laterally in each direction. Bladder blade was placed and bladder flap developed with blunt and sharp dissection. A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction. Allis was placed in the incision, and an uncomplicated extraction of a 7 pound 4 ounce, Apgar 9 female was accomplished and given to the pediatric service in attendance. Infant was carefully suctioned after delivery of the head and body. Cord blood was collected. _______ and endometrial cavity was wiped free of membranes and clots. Lower segment incision was inspected. There were some extensive adhesions on the left side and a figure-of-eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic. Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present. Cul-de-sac was suctioned free of blood and clots and irrigated. Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated. Lower segment incision was again inspected and found to be hemostatic. The abdominal wall was then closed in layers, 2-0 chromic on the peritoneum, 0 Maxon on the fascia, 3-0 plain on the subcutaneous and staples on the skin. Hemostasis was present between all layers. The area was gently irrigated across the peritoneum and fascial layers. There were no intraoperative complications except blood loss. The patient was taken to the recovery room in satisfactory condition.
## 404 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 33 weeks, twin gestation.,2. Active preterm labor.,3. Advanced dilation.,4. Multiparity.,5. Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1. Intrauterine pregnancy at 33 weeks, twin gestation.,2. Active preterm labor.,3. Advanced dilation.,4. Multiparity.,5. Requested sterilization.,6. Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7. Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:, Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section. The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm. The decision for C-section was made.,PROCEDURE:, The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision. The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia. The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors. The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically. The abdominal rectus muscle was divided in the center and extended in a vertical fashion. Peritoneum was entered at a high point and extended in a vertical fashion as well. The bladder blade was put in place. The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally. The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus. The first fetus was vertex. The fluid was clear. The head was delivered followed by the remaining portion of the body. The cord was doubly clamped and cut. The newborn handed off to waiting pediatrician and nursery personnel. The second fluid was ruptured. It was the clear fluid as well. The presenting part was brought down to be vertex. The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel. Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology. At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection. Then, there were multiple omental adhesions on the surface of the uterus itself. This needed to be released as well as on the abdominal wall and then the uterus could be externalized. The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first. The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath. The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized. The same technique was completed on the left side with the knuckle portion cut off and cauterized as well. The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis. Interceed was placed over this area as well. The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood. The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges. The abdominal rectus muscle was irrigated. The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center. The subcutaneous tissue was irrigated. Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue. Skin edges were re-approximated with sterile staples. Sterile dressing was applied. Uterus was evacuated of any remaining blood vaginally. The patient was taken to the recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct.
## 405 PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,POSTOPERATIVE DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,3. Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1. Repeat low transverse cesarean section.,2. Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:, A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9. There was normal pelvic anatomy, normal tubes. The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip. The abdomen was prepped and draped in a sterile fashion. A Pfannenstiel incision was made and carried sharply down to the level of fascia. The fascia was incised transversely. The fascia was dissected away from the underlying rectus muscles. With sharp and blunt dissection, rectus muscles were divided in midline. The perineum was entered bluntly. The incision was carried vertically with scissors. Transverse incision was made across the bladder peritoneum. The bladder was dissected away from the underlying lower uterine segment. Bladder retractor was placed to protect the bladder. The lower uterine segment was entered sharply with a scalpel. Incision was carried transversely with bandage scissors. Clear amniotic fluids were encountered. The infant was out of the pelvis and was in oblique vertex presentation. The head was brought down into the incision and delivered easily as were the shoulders and body. The mouth and oropharynx were suctioned vigorously. The cord was clamped and cut. The infant was passed off to the waiting pediatrician in satisfactory condition. Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact. Uterus was explored and found to be empty. Uterus was delivered through the abdominal incision and massaged vigorously. Intravenous Pitocin was administered. T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis. Secondary running locking stitch was placed for extra strength to the wound. At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut. Intervening knuckle was excised and passed off the field. The proximal end of the tubal mucosa was cauterized. Cul-de-sac and gutters were suctioned vigorously. The uterus was returned to its proper anatomic position in the abdomen. The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl. Uterus was expressed of its contents. Patient was brought to the recovery room in satisfactory condition. There were no complications. There was 600 cc of blood loss. All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.
## 406 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:, Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:, General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, 1200 cc.,FLUIDS:, 2700 cc.,URINE:, 400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS: ,Placenta, cord gases and cord blood.,INDICATIONS: ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions. She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm. A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally. There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained. The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery. She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this. After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered. She was then prepped and draped in the normal sterile fashion. Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered. Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife. The fascia was incised in the midline with a second knife. This incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps. It was then dissected in the midline with Mayo scissors. The inferior aspect of this incision was then addressed in a similar manner. The rectus muscles were then separated in the midline with a hemostat. The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly. Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors. This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly. Next, the bladder blade was placed. The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors. This incision was extended laterally in both directions and a bladder flap was created digitally. The bladder blade was then reinserted. Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife. Next, the uterine incision was extended laterally in both directions with the banded scissors. Next, the infant's head and body were delivered without difficulty. There was multiple section on the abdomen. The cord was clamped and cut. Section of cord was collected for gases and the cord blood was collected. Next, the placenta was manually extracted. The uterus was exteriorized and cleared of all clots and debris. The edges of the uterine incision were then identified with Allis _______ clamps. The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis. One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid. After several minutes of observation, the hematoma was seem to be non-expanding. The uterus was replaced in the abdomen. The uterine incision was reexamined and seem to be continuing to be hemostatic. The pelvic gutters were then cleared of all clots and debris. The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion. The peritoneum was then closed with #0 Vicryl in a running fashion. The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch. The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x3. The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital.
## 407 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy of 39 weeks.,2. Herpes simplex virus, positive by history.,3. Hepatitis C, positive by history with low elevation of transaminases.,4. Cephalopelvic disproportion.,5. Asynclitism.,6. Postpartum macrosomia.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy of 39 weeks.,2. Herpes simplex virus, positive by history.,3. Hepatitis C, positive by history with low elevation of transaminases.,4. Cephalopelvic disproportion.,5. Asynclitism.,6. Postpartum macrosomia.,7. Delivery of viable 9 lb female neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , About 600 cc.,Baby is doing well. The patient's uterus is intact, bladder is intact.,HISTORY: , The patient is an approximately 25-year-old Caucasian female with gravida-4, para-1-0-2-1. The patient's last menstrual period was in December of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions. The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases. The patient had been seen through our office for prenatal care. The patient is on Valtrex. The patient was found to be 3 cm about 40%, 0 to 9 engaged. Bag of waters was ruptured. She was on Pitocin. She was contracting appropriately for a couple of hours or so with appropriate ________. There was no cervical change noted. Most probably because there was a sink vertex and that the head was too large to descend into the pelvis. The patient was advised of this and we recommended cesarean section. She agreed. We discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms. The patient's questions were answered. I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,PROCEDURE: ,The patient was then taken back to operative suite. She was given anesthetic and sterilely prepped and draped. Pfannenstiel incision was used. A second knife was used to carry the incision down to the anterior rectus fascia. Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature. The rectus muscles were separated. The patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity. There was a very thin lower uterine segment. There seemed to be quite a large baby. The patient had a small nick in the uterus. Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained. A blunt low transverse cervical incision was made. Following this, we placed a ________ on the very large fetal head. The head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry. The patient then underwent removal of the placenta after the cord blood and ABG were taken. The patient's uterus was examined. There appeared to be no retained products. The patient's uterine incision was reapproximated and sutured with #0 Vicryl in a running non-interlocking fashion, the second imbricating over the first. The patient's uterus was hemostatic. Bladder flap was reapproximated with #0 Vicryl. The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic. We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures. The patient had three interrupted sutures of this. The fascia was reapproximated with two stitches of #0 Vicryl going from each apex towards the midline. The Scarpa's fascia was reapproximated with #0 gut. There was noted no fascial defects and the skin was closed with #0 Vicryl.,Prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact. The patient was hemostatic. All counts were correct and the patient tolerated the procedure well. We will see her back in recovery.
## 408 PREOPERATIVE DIAGNOSES:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,5. Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:, 500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS: ,Normal appearing uterus, tubes, and ovaries. A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively. Infant weight equaled to 4140 gm with clear amniotic fluid. The umbilical cord was wrapped around the leg tightly x1. Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE: ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy. She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery. The patient had a positive group beta strep colonization culture and was started on penicillin. The patient was also started on Pitocin protocol at that time. The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor. IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units. The patient was given a rest from the Pitocin. She walked and had a short shower. The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions. Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position. At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound. Options were discussed with the patient and family and it was determined that we will take her for C-section today. Consent was signed. All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed. She was placed in the dorsal supine position with left upward tilt. She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate. A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel. The fascia was incised in the midline and extended laterally using curved Mayo scissors. The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles. Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle. The rectus muscle was separated in the midline bluntly. The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors. The peritoneum was then bluntly stretched. The bladder blade was placed. The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors. The incision was extended laterally and the bladder flap created digitally. The bladder blade was then reinserted in the lower uterine segment. A low transverse uterine incision was made with a second scalpel. The uterine incision was extended laterally bluntly. The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum. Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically. There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut. Infant was handed to the waiting pediatrician. Cord gas was sent for pH as well as blood typing. The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris. The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion. A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis. The uterus was returned to the abdomen. The gutters were cleared of all clots and debris. The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion. The fascia was reapproximated with #0-Vicryl suture in a running fashion. The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut. The skin was then closed with staples. The incision was dressed with sterile dressing and bandage. Blood clots were evacuated from the vagina. The patient tolerated the procedure well. The sponge, lap, and needle counts were correct x2. The mother was taken to the recovery room in stable and satisfactory condition.
## 409 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,POSTOPERATIVE:,1. Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. Protein S low.,3. Oligohydramnios.,4. Delivery of a viable female, weight 5 pound, 14 ounces. Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:, Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS: ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction. The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration. Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department. The patient was then repositioned, prepped and draped in a slight left lateral tilt. Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in transverse fashion. Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique. The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion. Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade. Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus. Presenting part was vertex, the head was delivered, followed by the remaining portion of the body. The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel. Cord pH blood and cord blood was obtained. The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first. The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum. This area was then irrigated. Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center. Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl. Skin edges reapproximated with sterile staples. Sterile dressing was applied. The uterus was evacuated of any remaining clots vaginally. The patient was taken to recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct.
## 410 PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:, Primary cesarean section by low-transverse incision.,ANESTHESIA:, Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009. The patient began having prodromal symptoms 2 to 3 days prior to presentation. She was seen on 03/09/2007 and a nonstress test was performed. This revealed some spontaneous variable-appearing decelerations. She was given IV hydration. A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found. Therefore, she was admitted for further fetal monitoring and evaluation. She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated. She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute. Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion. This relieved the decelerations somewhat. However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations. Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery. These findings were reviewed with the patient and recommendation was made for cesarean section delivery. The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced. She was prepped and draped in the usual fashion for the procedure. After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall. This incision was carried down to the level of the fascia, which was also transversely incised. After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle. The rectus muscle was separated in midline exposing the peritoneum. The peritoneum was carefully grasped and elevated with hemostats. It was entered in an up and down fashion with Metzenbaum scissors. The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected. A thin lower uterine segment was noted. The vertex presentation was confirmed. The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall. Clear fluid was noted upon entering into the amniotic space. At 05:27, a term viable female infant was delivered up through the incision. She had spontaneous respirations. She was given bulb suctioning for clear fluid. Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending. The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes. Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity. A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis. The uterus was delivered up into the operative field. The endometrial cavity was swiped clean with a moist laparotomy pad. The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating. Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis. The uterine incision was noted to be hemostatic upon closure. The uterus was rotated forward, normal tubes and ovaries were noted on both sides. The uterus was then returned to its normal position of the abdominal cavity. The sponge and instrument count was performed for the first time at this point and found to be correct. The pelvis and anterior uterine space was then irrigated with saline solution. It was suctioned dry. A final check of the uterine incision confirmed hemostasis. The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture. The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline. The subcutaneous tissue was then irrigated and inspected. No active bleeding was noted. It was closed with a running length of 3-0 plain catgut suture. The skin was then approximated with surgical steel staples. The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic. The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition. The estimated blood loss through the procedure was 450 mL. The sponge and instrument counts were performed two more times during closure and found to be correct each time.
## 411 PREOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal fusion.,5. Two previous C-sections. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1. 36th and 4/7th week, intrauterine growth rate.,2. Charcot-Marie-Tooth disease.,3. Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4. Previous spinal effusion.,5. Two previous C-section. The patient refuses trial labor. The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6. Adhesions of bladder.,7. Poor fascia quality.,8. Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1. A repeat low transverse cervical cesarean section.,2. Lysis of adhesions.,3. Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4. The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:, 600 cc.,HISTORY AND INDICATIONS: ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus. The uterus appeared to be intact. This patient is a 26-year-old Caucasian female. The patient is well known to the OB/GYN clinic. The patient had two previous C-sections. She appears to be in probably early labor. She had an amniocentesis early today. She is contracting regularly about every three minutes. The contractions are painful and getting much more so since the amniocentesis. The patient had fetal lung maturity noted. The patient also has probable IUGR as none of her babies have been over 4 lb. The patient's baby appears to be somewhat small. The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound. The patient has had a spinal fusion, however, family planning is definitely complete per the patient. The patient refuses trial labor. The patient and I discussed the consent. She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery. Her questions were answered. The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy. The patient understands this and would like to try our best.,PROCEDURE: ,The patient was taken back to the operative suite. She was given general anesthetic by Department of Anesthesiology. Once again, in layman's terms, the patient understands the risks. The patient had the informed consent reviewed and understood. The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side. The patient had the first knife went through this incision. The second knife was used to go to the level of fascia. The fascia was very thin, ruddy in appearance, and with abundant scar tissue. The fascia was incised. Following this, we were able to see the peritoneum. There was really no obvious rectus abdominal muscles noted. They were very weak, atrophic, and thin. The patient has the peritoneum tented up. We entered the abdominal cavity. The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia. The bladder flap was then entered into the uterus as well. There are some bladder adhesions. We removed these adhesions and we removed the bladder of the fascia. We dissected the bladder of the lower segment. We made a small nick on the lower segment. We were able to utilize the blunt end of the knife to enter into the uterine cavity. The baby was in occiput transverse position with the ear being cocked at such a position as well. The patient's baby was delivered without difficulty. It was a 4 lb and 10 oz baby girl who vigorously cried well. There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection. The patient's placenta was delivered. There was no retained placenta. The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first. The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized. Then we ligated this as there was bleeding and oozing. The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc. The 400 cc was instilled. The bladder appears to be intact. The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment. There was some oozing around the area of the bladder. We placed an Avitene there. The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx. The patient has two clips on each side. There was excellent tubal occlusion and placement. The uterus was placed back into the abdominal cavity. We rechecked again. The tubal placement was excellent. It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx. The patient then underwent further examination. Hemostasis appeared to be good. The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia. We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible. The Scarpa's fascia was reapproximated with #0 gut. The skin was reapproximated then as well via subcutaneous closure. The patient's sponge and needle counts found to be correct. Uterus appeared to be normal prior to closure. Bladder appeared to be normal. The patient's blood loss is 600 cc.
## 412 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Arrest of dilation.,PROCEDURE PERFORMED:, Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS: ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces. Apgars were 9 at 1 minute and 9 at 5 minutes. Normal uterus, tubes, and ovaries were noted.,INDICATIONS: ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation. The patient progressed to 8 cm, at which time, Pitocin was started. She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm. A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery. Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE: ,The patient was taken to the operating room where epidural anesthesia was found to be adequate. The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt. A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was inserted. The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The bladder blade was reinserted. The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction. Clear fluid was noted. The infant was subsequently delivered atraumatically. The nose and mouth were bulb suctioned. The cord was clamped and cut. The infant was subsequently handed to the awaiting nursery nurse. Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform. Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was repaired in 2 layers using 0 chromic suture. Hemostasis was visualized. The uterus was returned to the abdomen.,The pelvis was copiously irrigated. The uterine incision was reexamined and was noted to be hemostatic. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
## 413 PREOPERATIVE DIAGNOSIS:, Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1. VATS right middle lobectomy.,2. Fiberoptic bronchoscopy thus before and after the procedure.,3. Mediastinal lymph node sampling including levels 4R and 7.,4. Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5. Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA: ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:, The right middle lobe tumor was adherent to the anterior chest wall. The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. The final frozen pathology on this entire area returned as negative for tumor. Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. Several other biopsies were taken and sent for permanent analysis of the chest wall. All of the biopsy sites were additionally marked with Hemoclips. The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:, This patient is well known to our service. He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident. Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. Sterile DuraPrep preparation on the right chest was placed. A sterile drape around that was also placed. The table was flexed to open up the intercostal spaces. A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. Marcaine was infused into all incision areas prior to making an incision. The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. All of these incisions were eventually created during the procedure. The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. The right middle lobe was noted to be adherent to the anterior chest wall. This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler. Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. This was encircled and divided with a blue load stapler with a 45-mm EndoGIA. Following division of this, the pulmonary artery was easily identified. Two branches of the pulmonary artery were noted to be going into the right middle lobe. These were individually divided with a vascular load after encircling with a right angle clamp. The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. This was divided with a blue load stapler 45 mm EndoGIA. Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port. Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package. Node station 8 or 9 nodes were easily identified, therefore none were taken. The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position. Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion. The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.
## 414 PREOPERATIVE DIAGNOSIS: ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1. Right thoracotomy.,2. Extensive lysis of adhesions.,3. Right lower lobectomy.,4. Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position. After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion. Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue. The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly. The chest was entered through the fifth intercostal space. A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection. The right lower lobe was identified. There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not. Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe. Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected. The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected. Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected. The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis. The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free. The mediastinum was then explored. No nodes were identified around the pulmonary ligament or around the esophagus. Subcarinal nodes were dissected, and hemostasis was obtained with clips. The space below and above the osseous was opened, and the station R4 nodes were dissected. Hemostasis was obtained with clips and with electrocautery. All nodal tissue were sent to Pathology as permanent specimen. Following this, the chest was thoroughly irrigated and aspirated. Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures. Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches. The incision was then closed with interrupted #2-0 Vicryl pericostal stitches. A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin. A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:, None.,COMPLICATIONS:, None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.
## 415 PREOPERATIVE DIAGNOSIS: ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section. The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner. A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia. Bleeding points were snapped and coagulated along the way. The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles. These were divided in the midline revealing the peritoneum, which was opened vertically. The uterus was in mid position. The bladder flap was incised elliptically and reflected caudad. A low transverse hysterotomy incision was then constructed and extended bluntly. Amniotomy revealed clear amniotic fluid. A live born vigorous male infant was then delivered from the right occiput transverse position. The infant breathed and cried spontaneously. The nares and pharynx were suctioned. The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team. Cord blood samples were obtained. The placenta was manually removed and the uterus was eventrated for closure. The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first. Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl. The cornual sac and gutters were irrigated. The uterus was returned to the abdominal cavity. The adnexa were inspected and were normal. The abdomen was then closed in layers. Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips. Blood loss was estimated at 700 mL. All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition.
## 416 OPERATION,1. Right upper lung lobectomy.,2. Mediastinal lymph node dissection.,ANESTHESIA,1. General endotracheal anesthesia with dual-lumen tube.,2. Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery. The 5th rib was counted, and the 6th interspace was entered. The lung was deflated. We identified the major fissure. We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery. Next, we used Bovie electrocautery to dissect the pleura off the lung. The pulmonary artery branches to the right upper lobe of the lung were identified. Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. This was done with suture ligature in combination with clips. After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. This likewise was ligated with a 0 silk. It was stick-tied with a 2-0 silk. It was then divided. Next we dissected out the bronchial branch to the right upper lobe of the lung. A curved Glover was placed around the bronchus. Next a TA-30 stapler was fired across the bronchus. The bronchus was divided with a #10-blade scalpel. The specimen was handed off. We next performed a mediastinal lymph node dissection. Clips were applied to the base of the feeding vessels to the lymph nodes. We inspected for any signs of bleeding. There was minimal bleeding. We placed a #32-French anterior chest tube, and a #32-French posterior chest tube. The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap. The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the PACU in good condition.
## 417 OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The left chest and back were prepped and draped in a sterile fashion. A right lateral thoracotomy incision was made. Subcutaneous flaps were raised. The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly. The posterior border of the pectoralis was freed up and it was retracted anteriorly. The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery. The major fissure was then taken down and arteries identified. The artery was dissected free and it was divided with an Endo GIA stapler. The vein was then dissected free and divided with an Endo GIA stapler. The bronchus was then cleaned of all nodal tissue. A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor. Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen. Hemostasis noted. Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl. A subcutaneous drain was placed. Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.
## 418 PREOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,PROCEDURES:,1. Revision, right breast reconstruction.,2. Excision, soft tissue fullness of the lateral abdomen and flank.,3. Liposuction of the supraumbilical abdomen.,ANESTHESIA: , General.,INDICATION FOR OPERATION:, The patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction. She now had lateralization of the implant with loss of medial fullness for which she desired correction. It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length. The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected. She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such. The above-noted procedure was discussed with the patient in detail. The risks, benefits and potential complications were discussed. She was marked in the upright position and then taken to the operating room for the above-noted procedure.,OPERATIVE PROCEDURE: , The patient was taken to the operating room and placed in the supine position. Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion. The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear. At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached. This was then opened. The implant was removed and placed on the back table in antibiotic solution. Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast. The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form. The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant. The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness. With this completed, the implant was again removed, antibiotic irrigation was performed. A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed. The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures. The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture. Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours. This was closed with 6-0 Prolene suture. The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus. A Kerlix dressing and a surgical bra was placed to the chest area. A compressive garment was placed. The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition. Sponge, needle, lap, instrument counts were all correct. The patient tolerated the procedure well. There were no complications. The estimated blood loss was approximately 25 mL.
## 419 PREOPERATIVE DIAGNOSIS:, Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY: ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA: ,General LMA.,FINDINGS: ,The patient was found to have a displaced fracture. She was found to be in perfect alignment after closed reduction and placement of cast. The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old. She was seen in our office today 1 week after being placed into a cast for a displaced fracture. She was noted to have significant loss of alignment especially on the lateral view. She was indicated for closed reduction and placed of the long-arm cast. Risks and benefits were discussed at length with the family. They wished to proceed.,PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in supine position. General anesthesia was induced without incident. Previous cast was previously removed. An arm was approached and a closed reduction was performed. This was checked under AP and lateral projection and was found to be in adequate alignment. There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding. Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass. The patient was awakened from anesthesia and taken to recovery room in good condition. There were no complications. All instruments, sponge, and needle counts were correct at the end of case.,PLAN: ,The patient will be discharged home. She will return in 3 weeks for cast removal and clinical examination. She would likely be placed into a wrist-guard at that time. She has a prescription for Tylenol with codeine elixir.,
## 420 PREOPERATIVE DIAGNOSIS:, Mass, left knee.,POSTOPERATIVE DIAGNOSIS: , Lipoma, left knee.,PROCEDURE PERFORMED: ,Excision of lipoma, left knee.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.,HISTORY:, The patient is a 35-year-old female with history of lump on her right knee for the past, what she reports to be six years. She states it had grow in size over the last six months, rarely causes her any discomfort or pain, denies any neurovascular complaints of her right lower extremity. She denies any other lumps or bumps on her body. She wishes to have this removed for cosmetic reasons.,PROCEDURE: , After all potential risks, benefits, and complications of the procedure were discussed with the patient, informed consent was obtained. She was transferred from the Preoperative Care Unit to Operating Suite #1. She was transferred from the gurney to the operating table. All bony prominences were well padded. A well padded tourniquet was applied to her right thigh. Anesthesia then administered some sedation, which she tolerated well. Her right lower extremity was then sterilely prepped and draped in normal fashion. Next, a rubber Esmarch was used to exsanguinate her right lower extremity.,Next, approximately 20 cc of 0.25% Marcaine with 1% lidocaine were used to locally anesthetize her anterior medial right knee in location of the mass. Next, a #15 blade Bard-Parker scalpel was utilized to make an approximately 3 cm vertical incision over the soft tissue mass upon incising the skin and the subcutaneous tissue readily and there was the aforementioned fatty tissue mass. This was easily excised with blunt dissection. Examination of the wound then revealed a second piece of fatty tissue, which resembled a lipoma measuring approximately 1.5 cm x 2 cm. This was then also excised utilizing Littler scissors. Hemostasis was obtained. The wound was then copiously irrigated after this all the underlying bone tissue was removed. #2-0 Vicryl interrupted subcutaneous sutures were then placed and the skin was reapproximated utilizing #4-0 horizontal mattress nylon sutures. Sterile dressings was applied of Adaptic, 4x4s, and Kerlix as well as an Ace wrap. Sedation was reversed. Tourniquet was deflated. The patient was transferred from the operating table to the gurney and to the Postoperative Care Unit in stable condition. Her prognosis for this is good.
## 421 PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position. Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy. An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold. A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle. 200 cc was infiltrated on each side. This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula. This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position. This would result in an elevation of the nipple-areolar complex with transposition. The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle. Hemostasis was achieved with electrocautery. After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple. Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture. Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing. The patient tolerated the procedure well. The patient was returned to recovery room in satisfactory condition.
## 422 PREOPERATIVE DIAGNOSIS:, Mass lesion, right upper extremity.,POSTOPERATIVE DIAGNOSIS: , Intramuscular lipoma, right arm, approximately 4 cm.,PROCEDURE PERFORMED: ,Excision of intramuscular lipoma with flap closure by Dr. Y.,INDICATIONS FOR PROCEDURE: ,This is a 77-year-old African-American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid-biceps region of the right upper extremity. The mass has been increasing in size and symptoms according to the patient. The risks and benefits of the surgical excision were discussed. The patient gave informed consent for surgical removal.,GROSS FINDINGS: , At the time of surgery, the patient was found to have intramuscular lipoma within the head of the biceps. It was removed in its entirety and submitted to Pathology for appropriate analysis.,PROCEDURE: , The patient was taken to the operating room. She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion. Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity. The skin and subcutaneous tissue were incised as well as the muscular fascia. The fibers of the biceps were divided bluntly and retracted. The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures. The mass was submitted to Pathology. Good hemostasis was seen. The wound was irrigated and closed in layers. The deep muscular fascia was reapproximated with #2-0 Vicryl suture.,The subcutaneous tissues were reapproximated with #3-0 Vicryl suture and the deep dermis was reapproximated with #3-0 Vicryl suture. Re-approximated wound flaps without tension and the skin was closed with #4-0 undyed Vicryl in running subcuticular fashion. The patient was given wound care instructions and will follow up again in my office in one week. Overall prognosis is good.
## 423 TITLE OF PROCEDURE: , Percutaneous liver biopsy.,ANALGESIA: , 2% Lidocaine.,ALLERGIES: , The patient denied any allergy to iodine, lidocaine or codeine.,PROCEDURE IN DETAIL: ,The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today. The patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death. The risks and benefits of the procedure were understood, and the patient signed the consent form freely.,With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion. The area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver. Next, a small incision was made with a Bard-Parker #11 scalpel. A 16-gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration. Liver cores measuring *** cm were obtained and will be sent to Pathology for routine histologic study.,POST-PROCEDURE COURSE AND DISPOSITION: , The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication. Normal activities can be resumed tomorrow. The patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop. An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,COMPLICATIONS:, None.,RECOMMENDATIONS: , Prior to discharge, hepatitis A and B vaccines will be recommended. Risks and benefits for vaccination have been addressed and the patient will consider this option.
## 424 PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:, Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:, General.,FINDINGS AND PROCEDURE:, With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion. After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus. Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen. A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood. Attention was then directed to the thighs both inner and outer. A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs. After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh. The patient tolerated the procedure very well. All of this aspirate was mostly fat with little fluid and very little blood. Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied. The patient tolerated the procedure very well and was sent to the recovery room in good condition.
## 425 PREOPERATIVE DIAGNOSES:,1. Torn anterior cruciate ligament, right knee.,2. Patellofemoral instability, right knee.,3. Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1. Complete tear anterior cruciate ligament, right knee.,2. Complex tear of the posterior horn lateral meniscus.,3. Tear of posterior horn medial meniscus.,4. Patellofemoral instability.,5. Chondromalacia patella.,PROCEDURES PERFORMED:,1. Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2. Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3. Partial medial meniscectomy.,4. Partial chondroplasty of patella.,5. Lateral retinacular release.,6. Open medial plication as well of the right knee.,ANESTHESIA:, General.,COMPLICATIONS:, None.,TOURNIQUET TIME:, 130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint. The patella was noted to be situated laterally past the lateral femoral condyle. There was a tear to the posterior horn of the medial meniscus within the white zone. There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus. There was a complete tear of the anterior cruciate ligament. The posterior cruciate ligament appeared intact. Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August. She was diagnosed per MRI. An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear. She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations. She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint. All risks and benefits of surgery were discussed with her at length. She was in agreement with the treatment plan.,PROCEDURE: ,On 09/11/03, she was taken to the operating room at ABCD General Hospital. She was placed supine on the operating table. General anesthetic was applied by the Anesthesiology Department. Tourniquet was placed on the proximal thigh and it was then placed in a knee holder. She was sterilely prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. Longitudinal incision was made just medial to the tibial tubercle. The subcutaneous tissue was carefully dissected. Hemostasis was controlled with electrocautery. The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction. They were taken on the back table. The soft tissue debris was removed from the tendons. The ends of the tendons were sewn together using #5 Tycron whip type sutures. The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table. Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee. The knee was inflated with saline solution and operative pictures were obtained. The above findings were noted. A second port site was initiated in the inferomedial parapatellar region. Through this, a probe was placed. Tear in the posterior horn medial meniscus was identified. It was resected using a meniscal resector. It was then further contoured using arthroscopic shaver. Attention was then taken to the lateral compartment. A partial meniscectomy was performed using the resector and the shaver. The posterior periphery of the lateral meniscus was also noticed to be unstable. A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon. There was noted to be excellent fixation. The shaver was then taken into the intrachondral notch. First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint. Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle. Next, a tibial guide was placed through the anterior medial portal. A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament. This tibial tunnel was then drilled using 8 mm cannulated drill. Next, an over-the-top guide was then placed at approximately the 11:30 position. A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm. Next the U shape guide was placed through tibial tunnel into the femur. A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur. It was then pulled out through the tibial tunnel using the You-shaped guide. The tendon was then placed around the wire. The wire was pulled back up through the tibial into the femoral tunnel. A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons. Attention was then pulled through the tibial tunnel. The knee was cycled approximately 20 times. A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft. There was noted definite fixation of the graft. There was no evidence of impingement either in full flexion or full extension. The knee was copiously irrigated and it was then suctioned dry. A longitudinal incision was made just medial to the patellofemoral joint. Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision. Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication. The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture. The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch. She was placed in a DonJoy knee immobilizer. The tourniquet was deflated. It was noted the lower extremity was warm and pink with good capillary refill. She was transferred to the recovery room in apparent stable and satisfactory condition. Prognosis for this patient is guarded. She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension. She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal. She will require one to two more physical therapy to help regain motion and strength to the lower extremity.
## 426 OPERATION PERFORMED:, Ligament reconstruction and tendon interposition arthroplasty of right wrist.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint. Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field. Further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium. An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint. Sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon. The radial beak of the trapezoid was then osteotomized off the head of the scaphoid. The proximal metacarpal was then fenestrated with a 4.5-mm drill bit. Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision. The FCR tendon was divided and this incision was closed with 4-0 nylon sutures. Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound.,The FCR tendon was then threaded through the fenestration in the metacarpal. A bone anchor was then placed distal to the metacarpal fenestration. The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position. The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor. Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect. The MP joint was brought into extension and the capsule closed using interrupted 3-0 Tycron sutures.,Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0.035 Kirschner wire. The pin was cut at the level of the skin.,All incisions were closed with running 3-0 Prolene subcuticular stitch.,Sterile dressings were then applied. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
## 427 PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.
## 428 PREOPERATIVE DIAGNOSES:,1. Hoarseness.,2. Bilateral true vocal cord lesions.,3. Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1. Hoarseness.,2. Bilateral true vocal cord lesions.,3. Leukoplakia.,PROCEDURE PERFORMED: ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office. Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia. A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx. The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords. The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third. The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region. The patient's anterior commissure appeared to be clear. The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord. Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect. The patient's subglottic region was very edematous and with redundant mucosal tissue. The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch. The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps. After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis. The specimen was passed off the field and was sent to Pathology for evaluation. Hemostasis was maintained on the left side. Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand. The Zeiss operating microscope was then brought into view to directly visualize the vocal cords. The biopsies were taken under direct visualization utilizing the Zeiss operating microscope. After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full. This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen. The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions. A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions. There were no signs of any palpable cervical lymphadenopathy. The tooth guard was removed and the patient was then turned back to anesthesia. The patient did receive intraoperatively 10 mg of Decadron. The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well. The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.
## 429 PREOPERATIVE DIAGNOSIS: ,Lateral epicondylitis.
## 430 ASSESSMENT: ,The patient needed reintubation due to a leaking tube. I explained to the patient the procedure that I was going to do and he nodded in seeming understanding of the procedure.,Using Versed and succinylcholine, we were able to sedate and paralyze him to perform the procedure. His potassium this morning was normal. Using an 8.5 ET tube under direct visualization, the tube was passed through the cords. The patient tolerated the procedure extremely well. Auscultation of the lungs revealed bilateral equal breath sounds. Chest x-ray is pending. CO2 monitor was positive.
## 431 PREOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,SURGERY: ,Cystopyelogram and laser vaporization of the prostate.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is a 67-year-old male with a history of TURP, presented to us with urgency, frequency, and dribbling. The patient was started on alpha-blockers with some help, but had nocturia q.1h. The patient was given anticholinergics with minimal to no help. The patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate. At this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream. Continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed. The patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder. The patient was told that he may need anticholinergics. There could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,PROCEDURE IN DETAIL: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was given preoperative antibiotics. The patient was prepped and draped in the usual sterile fashion. A #23-French scope was inserted inside the urethra into the bladder under direct vision. Bilateral pyelograms were normal. The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder. There was enlargement of the lateral lobes of the prostate. The old TUR scar was visualized right at the bladder neck. Using diode side-firing fiber, the lateral lobes were taken down. The verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure. Pictures were taken and were shown to the family. At the end of the procedure, there was good hemostasis. A total of about 15 to 20 minutes of lasering time was used. A #22 3-way catheter was placed. At the end of the procedure, the patient was brought to recovery in stable condition. Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night.
## 432 PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis. She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007. She returns with some increasing shortness of breath and dyspnea on exertion. Endoscopic reevaluation is offered to her. The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms. An endoscopic treatment was offered to her. Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position. Following adequate general anesthesia, the patient was prepared for endoscopy. The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition. Tongue and buccal cavity mucosa were without ulcers, masses, or lesions. The oropharynx was clear. The larynx was then manually suspended. Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent. The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds. At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred. Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated. Remainder of the bronchi was then examined. The mid and distal trachea were widely patent. Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring. The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out. Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished. Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia. The patient tolerated the procedure well without complication.
## 433 PREOPERATIVE DIAGNOSIS: , Left testicular torsion.,POSTOPERATIVE DIAGNOSES: ,1. Left testicular torsion.,2. Left testicular abscess.,3. Necrotic testes.,SURGERY:, Left orchiectomy, scrotal exploration, right orchidopexy.,DRAINS:, Penrose drain on the left hemiscrotum.,The patient was given vancomycin, Zosyn, and Levaquin preop.,BRIEF HISTORY: ,The patient is a 49-year-old male who came into the emergency room with 2-week history of left testicular pain, scrotal swelling, elevated white count of 39,000. The patient had significant scrotal swelling and pain. Ultrasound revealed necrotic testicle. Options such as watchful waiting and removal of the testicle were discussed. Due to elevated white count, the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis. The risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, scrotal issues, other complications were discussed. The patient was told about the morbidity and mortality of the procedure and wanted to proceed.,PROCEDURE IN DETAIL: , The patient was brought to the OR. Anesthesia was applied. The patient was prepped and draped in usual sterile fashion. A midline scrotal incision was made. There was very, very thick scrotal skin. There was no necrotic skin. As soon as the left hemiscrotum was entered, significant amount of pus poured out of the left hemiscrotum. The testicle was completely filled with pus and had completely disintegrated with pus. The pus just poured out of the left testicle. The left testicle was completely removed. Debridement was done of the scrotal wall to remove any necrotic tissue. Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum. There was good tissue left after all the irrigation and debridement. A Penrose drain was placed in the bottom of the left hemiscrotum. I worried about the patient may have torsed and then the testicle became necrotic, so the plan was to pex the right testicle, plus the right side also appeared very abnormal. So, the right hemiscrotum was opened. The testicle had significant amount of swelling and scrotal wall was very thick. The testicle appeared normal. There was no pus coming out of the right hemiscrotum. At this time, a decision was made to place 4-0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion. The hemiscrotum was closed using 2-0 Vicryl in interrupted stitches and the skin was closed using 2-0 PDS in horizontal mattress. There was very minimal pus left behind and the skin was very healthy. Decision was made to close it to help the patient heal better in the long run. The patient was brought to the recovery in stable condition.
## 434 PREOPERATIVE DIAGNOSIS: , Recurrent dysplasia of vulva.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION PERFORMED:, Carbon dioxide laser photo-ablation.,ANESTHESIA: , General, laryngeal mask.,INDICATIONS FOR PROCEDURE: , The patient has a past history of recurrent vulvar dysplasia. She has had multiple prior procedures for treatment. She was counseled to undergo laser photo-ablation.,FINDINGS:, Examination under anesthesia revealed several slightly raised and pigmented lesions, predominantly on the left labia and perianal regions. After staining with acetic acid, several additional areas of acetowhite epithelium were seen on both sides and in the perianal region.,PROCEDURE: ,The patient was brought to the operating room with an IV in place. Anesthetic was administered, after which she was placed in the lithotomy position. Examination under anesthesia was performed, after which she was prepped and draped. Acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion. The carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined Reid. Setting was 25 watts using a 6 mm pattern size with the silk-touch hand piece in the paint mode. Excellent hemostasis was noted and Bacitracin was applied prophylactically. The patient was awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
## 435 DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.
## 436 TITLE OF OPERATION:, Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07. Subsequently, biopsy confirmed tumor persistence in the right glottic region. Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail. Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level. The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives. He was accompanied by his wife and daughter. Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table. After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm. A #6 endotracheal tube was placed initially. Direct laryngoscopy was performed with a Lindholm laryngoscope. A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis. Subsequently, a decision was then made to go ahead and perform the surgical intervention. A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected. A shoulder roll was applied after the patient was prepped and draped in a sterile fashion. Subsequently, a hemi-apron incision was performed. Subplatysmal flaps were raised at the hyoid bone into the clavicle. Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed. Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle. Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle. The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified. Level 2A contents were then dissected off the floor of the neck including levels 3 and 4. Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4. The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve. Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed. Subsequently, the strap muscles were separated in the midline. The trachea was identified in the midline. The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage. Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively. The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular. Attention was then turned to performing a cricothyrotomy. Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision. A #7 anode tube was then placed in this area and secured. Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis. Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine. It was evident that this tumor had extended more than 1 cm into the subglottic region. Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded. Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy. Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin. A W-plasty was also performed to allow for enlargement of the stoma. Attention was then turned to identifying the common parting wall of the trachea and the esophagus. Attention was then turned to resecting the hyoid bone. The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism. The wound was copiously irrigated. Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect. Once this was performed, a running 3-0 canal stitch was used to close the pharynx. Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied. Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon. The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin. The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.
## 437 PREOPERATIVE DIAGNOSES:,1. Right ectopic pregnancy.,2. Severe abdominal pain.,3. Tachycardia.,POSTOPERATIVE DIAGNOSES:,1. Right ectopic pregnancy.,2. Severe abdominal pain.,3. Tachycardia.,PROCEDURE PERFORMED:, Exploratory laparotomy and right salpingectomy.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , 200 mL.,COMPLICATIONS: ,None.,FINDINGS: , Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity. Normal-appearing ovaries bilaterally, normal-appearing left fallopian tube, and normal-appearing uterus.,INDICATIONS: ,The patient is a 23-year-old gravida P2, P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain. The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08/08 and treated appropriately and adequately with methotrexate. Evaluation in the emergency room reveals a second right ectopic pregnancy. Her beta quant was found to be approximately 13,000. The ultrasound showed right adnexal mass with crown-rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity. Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy. The procedure was discussed with the patient in detail including risks of bleeding, infection, injury to surrounding organs and possible need for further surgery. Informed consult was obtained prior to proceeding with the procedure.,PROCEDURE NOTE: ,The patient was taken to the operating room where general anesthesia was administered without difficulty. The patient was prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to grasp the superior aspect of the fascial incision, which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors, attention was then turned to the inferior aspect, which was grasped with Kocher clamps, elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors. The rectus muscles were dissected in the midline. The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder. At this time, the blood found in the abdomen was suctioned. The bowel was packed with moist laparotomy sponge. The right ectopic pregnancy was identified. The fallopian tube was clamped x2, excised, and ligated x2 using 0-Vicryl suture. Hemostasis was visualized. At this time, the left tube and ovary were examined and were found to be normal in appearance. The pelvis was cleared off clots and was copiously irrigated. The fallopian tube was reexamined and it was noted to be hemostatic.,At this time, the laparotomy sponges were removed. The rectus muscles were reapproximated using 3-0 Vicryl. The fascia was reapproximated with #0 Vicryl sutures. The subcutaneous layer was closed with 3-0 plain gut. The skin was closed with 4-0 Monocryl. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
## 438 PREOPERATIVE DIAGNOSES:,1. Acute pain.,2. Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1. Acute pain.,2. Fever postoperatively.,3. Hemostatic uterine perforation.,4. No bowel or vascular trauma.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:, None.,INDICATIONS: ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03. The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2. The patient denied any nausea, vomiting or diarrhea. She does complain of some frequent urination. Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated. On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus. There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac. The bilateral tubes and ovaries appeared normal. There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap. There is no evidence of injury to the bowel or pelvic sidewall. The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed. Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made. Veress needle was placed through this incision and the gas turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. A 11 mm trocar was then placed through this incision. The camera was placed with the above findings noted. A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline. A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs. The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline. At this point, Dr. X was consulted. He performed a rigid sigmoidoscopy, please see his dictation for further details. There does not appear to be any evidence of colonic injury. The saline in the pelvis was then suctioned out using Nezhat-Dorsey. All instruments were removed. The 5 mm trocar was removed under direct visualization with excellent hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar removed. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief. Steri-Strips were then placed across the incision. The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of the procedure. The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics.
## 439 PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain. The patient was found to have cholelithiasis on last admission. He was being worked up for this including cardiac clearance. However, in the interim, he returned again with another episode of same pain. The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction. Because of these, laparoscopic cholecystectomy was advised with cholangiogram. Possibility of open laparotomy and open procedure was also explained to the patient. The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia. The entire abdomen was prepped and draped. A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia. The patient has a rather long torso. Fascia was opened vertically and stay sutures were placed in the fascia. Peritoneal cavity was carefully entered. Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2. Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area. The patient was placed in reverse Trendelenburg and rotated to the left. An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. Slowly, the dissection was carried out in the right subhepatic area. Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver. Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation. The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick. After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy. The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered. A Bookwalter retractor was put in place. The dissection was then carried out on the undersurface of the liver. Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it. Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size. The duodenum was kocherized. The gallbladder was partly intrahepatic. Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem. The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was. Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short. Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy. This showed a rounded density at the lower end of the bile duct consistent with the stone. At this time, a decision was made to proceed with common duct exploration. The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out. After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct. So, it was about a 1-cm size stone, which was removed. Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously. No further stones were obtained. The catheter went easily into the duodenum through the ampulla of Vater. At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree. However, a stone was found distally still floating around. This was removed with stone forceps. The bile ducts were irrigated again. No further stones were removed. A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure. A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area. Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area. I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct. The bile duct lumen was widely open. T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time. The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining. Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. Hemostasis was good. A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site. The T-tube was brought out through the middle 5-mm port site, which was just above the incision. Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia. Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers. Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control. The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin. Sterile dressing was applied, and the patient transferred to recovery room in stable condition.
## 440 PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,PROCEDURE PERFORMED:,1. Laparotomy.,2. Myomectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS: ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium. Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position. After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife. This was carried through the underlying layer of fascia with a second knife. The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly. It was then dissected in the middle with the Mayo scissors. The inferior aspect of this incision was addressed in a similar manner. The rectus muscles were separated in the midline bluntly. The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly. Next, the uterus was grasped bluntly and removed from the abdomen. The fundal fibroid was identified. It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels. 15 cc was injected. Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen. The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger. The fibroid was easily and bluntly dissected out. It was also grasped with Lahey clamp to prevent traction. Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse. The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed. At this point, several smaller fibroids were noticed along the endometrial surface of the uterus. Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size. These were also handed to the scrub tech. Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch. The uterus was seen to be completely hemostatic after closure. Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline. The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed. Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline. Then the fascia was closed with #0 Vicryl in a running fashion. Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion. The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately. After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.
## 441 PREOPERATIVE DIAGNOSIS: , Chronic pelvic pain, probably secondary to endometriosis.,POSTOPERATIVE DIAGNOSIS:, Mild pelvic endometriosis.,PROCEDURE:,1. Attempted laparoscopy.,2. Open laparoscopy.,3. Fulguration of endometrial implant.,ANESTHESIA: , General endotracheal.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS: ,The patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative GI workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of Depo-Lupron.,PROCEDURE: , After an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position. She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery. Bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,In the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall. The anterior lip of the cervix was grasped with a single-tooth tenaculum. A Hulka tenaculum was placed transcervically. The other instruments were removed. A Foley catheter was placed transurethrally to drain the bladder intraoperatively.,In the low lithotomy position and in steep Trendelenburg, attention was turned to the infraumbilical region. Here, a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum. The needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed. The trocar was removed and the scope placed confirming a preperitoneal insufflation.,The space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity. Attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion. The Hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long Allis clamp used to grasp the posterior fornix on which was placed traction. The first short and subsequently 15 cm Veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also. It was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area. The 15 cm Veress needle was inserted several times, but again a pneumo was preperitoneal.,Finally, an open laparoscopic approach was undertaken. The skin incision was expanded with a knife blade. Blunt dissection was used to carry the dissection down to the fascia. This was grasped with Kocher clamps, entered sharply and opened transversely. Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff. Dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,At this juncture, the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,Under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed. Clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary. In the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting. The left tube and ovary were normal. There were no adhesions. There was no evidence of acute pelvic inflammatory disease.,The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated. Pictures were taken for confirmation both before and after the burn.,The carbon chars were irrigated and aspirated. The smoke plume was removed without difficulty. Approximately 50 mL of irrigant was left in the pelvis. Due to the difficulty in placing and maintaining the Hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,The suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the Hasson cannula removed. The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site. Finally, the skin incisions were approximated with 3-0 Dexon subcuticularly. They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies. The vaginal instruments were removed. All counts were correct. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
## 442 PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac. Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE: ,The patient was taken to the operating room and placed under general anesthesia. She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner. Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated. Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed. Laparoscope was inserted through the cannula and the pelvis was visualized. Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline. Incision sites were transilluminated and injected with Marcaine prior to cutting. Hulka manipulator was placed on the cervix. Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac. The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis. Some more lesions were noted above the left uterosacral ligament. Flame lesions were noted above the right uterosacral ligament. Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube. There was a somewhat leathery appearance to the ovaries. The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window. Pelvis was irrigated and all operative sites were hemostatic. No other abnormalities were visualized and all instruments were moved under direct visualization. Approximately 200 mL of fluid remained in the abdominal cavity. All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape. The patient was taken to the recovery in stable condition.
## 443 PREOPERATIVE DIAGNOSIS,1. Dysmenorrhea.,2. Menorrhagia.,POSTOPERATIVE DIAGNOSIS,1. Dysmenorrhea.,2. Menorrhagia.,PROCEDURE:, Laparoscopic supracervical hysterectomy.,ESTIMATED BLOOD LOSS:, 30 cc.,COMPLICATIONS:, None.,INDICATIONS FOR SURGERY: , A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management. Please see clinic notes. Risks of bleeding, infection, damage to other organs have been explained. Informed consent was obtained.,OPERATIVE FINDINGS:, Slightly enlarged but otherwise normal-appearing uterus. Normal-appearing adnexa bilaterally.,OPERATIVE PROCEDURE IN DETAIL: , After administration of general anesthesia the patient was placed in dorsal lithotomy position, prepped and draped in the usual sterile fashion. Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field. A 5 mm incision was made umbilically after injecting 0.25% Marcaine; 0.25% Marcaine was injected in all the incisional sites. Veress needle was inserted, position confirmed using the saline drop method. After confirming an opening pressure of 4 mmHg of CO2 gas, approximately four liters was insufflated in the abdominal cavity. Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope. A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side. All these were placed under direct visualization. Pelvic cavity was examined with findings as noted above. The left utero-ovarian ligament was grasped and cauterized using the Gyrus. Part of the superior aspect of the broad ligament was then cauterized as well. Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment. The remainder of the broad and cardinal ligament was then cauterized and excised. A similar procedure was performed on the right side. The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament. After assuring that the bladder was well out of the way of the operative field, bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments. The area was irrigated extensively and cautery used to assure hemostasis. A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination. Hemostasis was again confirmed under low pressure. Using Carter-Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture. The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5-0 Monocryl suture. Instruments removed from vagina. Patient returned to supine position, recalled from general anesthesia and transferred to recovery in satisfactory condition. Sponge and needle counts correct at the conclusion of the case. Estimated blood loss was 30 cc. There were no complications.
## 444 PREOPERATIVE DIAGNOSIS: , Right lower quadrant abdominal pain, rule out acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Acute suppurative appendicitis.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Appendix.,COMPLICATIONS: , None.,BRIEF HISTORY: , This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation. She admits to some nausea associated with it. There have been no fevers, chills, and/or genitourinary symptoms. The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant. She had a leukocytosis of 12.8. She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis. Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy. The risks, benefits, complications of the procedure, she gave us informed consent to proceed.,OPERATIVE FINDINGS: ,Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged. The left ovary revealed some follicular cysts. There was no evidence of adnexal masses and/or torsion of the fallopian tubes. The uterus revealed no evidence of mass and/or fibroid tumors. The remainder of the abdomen was unremarkable.,OPERATIVE PROCEDURE: , The patient was brought to the operative suite, placed in the supine position. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. The patient underwent general endotracheal anesthesia. The patient also received a preoperative dose of Ancef 1 gram IV. After adequate sedation was achieved, a #10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle. Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg. Once the abdomen was sufficiently insufflated, a 10 mm bladed trocar was inserted into the abdomen without difficulty. A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored. Next, a 5 mm port was inserted in the midclavicular line of the right upper quadrant region. This was inserted under direct visualization. Finally, a suprapubic 12 mm portal was created. This was performed with #10 blade scalpel to create a transverse incision. A bladed trocar was inserted into the suprapubic region. This was done again under direct visualization. Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum. This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly. Utilizing a endovascular stapling device, the appendix was transected and doubly stapled with this device. Next, the mesoappendix was doubly stapled and transected with the endovascular stapling device. The staple line was visualized and there was no evidence of bleeding. The abdomen was fully irrigated with copious amounts of normal saline. The abdomen was then aspirated. There was no evidence of bleeding. All ports were removed under direct visualization. No evidence of bleeding from the port sites. The infraumbilical and suprapubic ports were then closed. The fascias were then closed with #0-Vicryl suture on a UR6 needle. Once the fascias were closed, all incisions were closed with #4-0 undyed Vicryl. The areas were cleaned, Steri-Strips were placed across the wound. Sterile dressing was applied.,The patient tolerated the procedure well. She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition. She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course.
## 445 <NA>
## 446 PREOPERATIVE DIAGNOSIS:, Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Pelvic endometriosis.,3. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Laparoscopy.,2. Harmonic scalpel ablation of endometriosis.,3. Lysis of adhesions.,4. Cervical dilation.,ANESTHESIA: ,General.,SPECIMEN: ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:, Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. There are adhesions involving the right ovary to the anterior abdominal wall and the bowel. There are also adhesions from the omentum to the anterior abdominal wall near the liver. The uterus and ovaries appear within normal limits other than the adhesions. The left fallopian tube grossly appeared within normal limits. The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized. There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac. There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE: ,The patient was taken in the operating room and generalized anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. After exam under anesthetic, weighted speculum was placed in the vagina. The anterior lip of the cervix was grasped with vulsellum tenaculum. The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen. An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife. The superior aspect of the umbilicus was grasped with a towel clamp. The abdomen was tented up and a Veress needle inserted through this incision. When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle. This was seen to freely drop in the abdomen so it was connected to CO2 gas. Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting. The abdomen was then insufflated to an adequate distention. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. Next, the laparoscope was inserted through this port. The medial port was connected to CO2 gas. Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis. Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed. Next, a grasper was placed through the suprapubic port. This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions. Bowel was carefully examined afterwards and no injuries or bleeding were seen. Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty. There was a small amount of bleeding from the anterior abdominal wall peritoneum. This was ablated with the Harmonic scalpel. The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac. Both of these areas were seen to be hemostatic. Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac. This was sent to pathology. Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed. It was seen to be completely hemostatic. Next, the two size #5 ports were removed under direct visualization. The camera was removed. The abdomen was desufflated. The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.
## 447 PREOPERATIVE DIAGNOSIS:, Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:, General,NAME OF OPERATION:, Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:, The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced. An infraumbilical incision was made, and Veress needle placed without difficulty. Gas was entered into the abdomen at two liters. The laparoscope was entered, and the abdomen was visualized. The second puncture site was made, and the second trocar placed without difficulty. The cyst was noted on the left, a 3-cm, ovarian cyst. This was needled, and a hole cut in it with the scissors. Hemostasis was intact. Instruments were removed. The patient was awakened and taken to the recovery room in good condition.
## 448 PREOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes, bilateral intraabdominal testes.,PROCEDURE: , Examination under anesthesia and laparoscopic right orchiopexy.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS RECEIVED: ,110 mL of crystalloid.,INTRAOPERATIVE FINDINGS: , Atrophic bilateral testes, right is larger than left. The left had atrophic or dysplastic vas and epididymis.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION: ,The patient is a 7-1/2-month-old boy with bilateral nonpalpable testes. Plan is for exploration, possible orchiopexy.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then palpated and again both testes were nonpalpable. Because of this, a laparoscopic approach was then elected. We then sterilely prepped and draped the patient, put an 8-French feeding tube in the urethra, attached to bulb grenade for drainage. We then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors. Once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens. Insufflation was then done with carbon dioxide up to 10 to 12 mmHg. We then evaluated. There was no bleeding noted. He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized. The right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring. So, we elected to do an orchiopexy on the right side. Using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas. We then used the Maryland dissector to gently tease this tissue once it was incised. The gubernaculum was then divided with electrocautery and the laparoscopic scissors. We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring. We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery. We used the curved tenotomy scissors to make a subdartos pouch. Using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation. Using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction. Using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis. We then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic. We again evaluated the left side and found again that the vessels were quite short. The testis was more atrophic, and the vas was virtually nonexistent. We will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present. We then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 Monocryl, closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath, and then used 4-0 Rapide to close the skin defects, and then using Dermabond tissue adhesives, we covered all incisions. At the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed. The patient had IV Toradol and was in stable condition upon transfer to recovery room.
## 449 PREOPERATIVE DIAGNOSIS:, Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:, Left ovarian lesion.,PROCEDURE PERFORMED: ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:, None.,FINDINGS:, The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled. There were a few calcifications on the surface of the mass. The right ovary and fallopian tube appeared normal. There was no evidence of endometriosis. The uterus appeared normal in size. There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm. She does complain of minimal discomfort. Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position. A 1 cm skin incision was made in the infraumbilical vault. While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated. This was done using appropriate flow and volume of CO2. The #11 step trocar was then placed without difficulty. The above findings were confirmed. A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization. Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall. Both #12 step ports were done under direct visualization. Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating. The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision. The skin was extended around this incision and the fascia was extended using the Mayo scissors. The specimen was removed intact in the Endocatch bag through this site. Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic. All the port sites were hemostatic as well. The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated. Steri-Strips were placed on each of the incisions. The patient tolerated the procedure well. Sponge, lap, and needle count were x2. She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her.
## 450 PREOPERATIVE DIAGNOSIS:, Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:, Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer. She was counseled to undergo laparoscopic staging.,FINDINGS:, During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries. No ascites was present. On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered. She was placed in a low anterior lithotomy position using Allen stirrups. The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine. There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports. The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty. The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed. There were no adhesions underlying the previous vertical midline scar. The 10-mm port was placed in the umbilicus, and the laparoscope was inserted. Remaining ports were placed under direct laparoscopic guidance. Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy. An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum. The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached. Pedicles were sealed and divided with bipolar cutting forceps. Excellent hemostasis was noted. Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery. Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps. The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially. The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally. The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy. The right infundibulopelvic ligament was divided using the bipolar cutting forceps. The mesovarium was skeletonized. A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder. Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring. The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries. The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum. The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device. The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen. The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture. The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released. The umbilical port was removed using laparoscopic guidance. The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl. The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture. The final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was awakened and taken to the post anesthesia care unit in stable condition.
## 451 <NA>
## 452 PREOPERATIVE DIAGNOSIS: ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1. Right ureteropelvic junction obstruction.,2. Severe intraabdominal adhesions.,3. Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Attempted laparoscopic pyeloplasty.,3. Open laparoscopic pyeloplasty.,ANESTHESIA:, General.,INDICATION FOR PROCEDURE: ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent. The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic. The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction. Hassan technique was performed for the initial trocar placement in the periumbilical region. Abdominal insufflation was performed. There were significant adhesions noted. A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular. After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially. The kidney was able to be palpated within Gerota's fascia. The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter. The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction. The renal pelvis was also identified and dissected free. There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes. We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open. An incision was made from the right upper quadrant port extending towards the midline. This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum. A Bookwalter retractor was placed. The renal pelvis and the ureter were again identified. Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery. The tissue was sent down to Pathology for analysis. Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted. Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place. The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue. At this point, the indwelling double-J ureteral stent was removed. At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed. This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated. The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture. At this point, a double-J stent was placed with a guidewire down into the bladder. The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture. Renal sinus fat was then placed around the anastomosis and sutured in place. Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue. This was repaired with horizontal mattress sutures #2-0 Vicryl. FloSeal was placed over this and the renal capsule was placed over this. A good hemostasis was noted. A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis. The initial trocar incision was closed with #0 Vicryl suture. The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia. The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture. The skin edges were then closed with staples. Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator. We placed the patient on IV antibiotics and pain medications. We will obtain KUB and x-rays for stent placement. Further recommendations to follow.
## 453 PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS: ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful. She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent. The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room and placed supine on the operating room table. All pressure points were carefully padded. She was given general anesthesia with endotracheal intubation. SCD stockings were placed on both legs. Foley catheter was placed for bladder decompression. The abdomen was then prepped and draped in standard sterile surgical fashion. Marcaine was then injected through umbilicus. A small incision was made. A Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg. A 12-mm VersaStep port was placed through the umbilicus. I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side. I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port. On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port. A few centimeters below and medial to that, I placed a 15-mm port. I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz. I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler. I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device. I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis. I reapproximated the edges of the defect. I lifted it up and stapled across it with another white load stapler. I then closed the mesenteric defect with interrupted Surgidac sutures. I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic. I then put the patient in reverse Trendelenburg. I placed a liver retractor, identified, and dissected the angle of His. I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space. I fired transversely across the stomach with a 45 blue load stapler. I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch. I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil. I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler. I passed that in the end of my Roux limb and had the spike come out antimesenteric. I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag. I put some additional 2-0 Vicryl sutures in the anastomosis for further security. I then placed a bowel clamp across the bowel. I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch. I distended gastric pouch with air. There was no air leak seen. I could pass the scope easily through the anastomosis. There was no bleeding seen through the scope. We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason. I copiously irrigated out that incision with about 2 L of saline. I then closed the skin of all incisions with running Monocryl. Sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications.
## 454 PREOPERATIVE DIAGNOSIS: , Bilateral renal mass.,POSTOPERATIVE DIAGNOSIS:, Bilateral renal mass.,OPERATION: , Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 100 Ml.,FLUIDS: , Crystalloid.,The patient was bowel prepped and was given preoperative antibiotics.,BRIEF HISTORY: , The patient is a 73-year-old male, who presented to us with a referral from Dr. X's office with bilateral renal mass and renal insufficiency. The patient's baseline creatinine was around 1.6 to 1.7. The patient was found to have a 3 to 4-cm exophytic right renal mass, 1-cm renal mass inferior to that, and about 2-cm left renal mass. Since the patient had bilateral renal disease and the patient had renal insufficiency, the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy, one kidney at a time. The patient understood all his options, had done some research on cryotherapy and wanted to proceed with the procedure. The patient had a renal biopsy done, which showed a possibility of an oncocytoma, which also would indicate that if this is not truly a cancerous lesion, but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney.,Risk of anesthesia, bleeding, infection, pain, hernia, bowel obstruction, ileus, injury to bowel, postoperative bleeding, etc., were discussed. The patient understood the risk of delayed bleeding, the needing for nephrectomy, renal failure, renal insufficiency, etc., and wanted to proceed with the procedure.,DETAILS OF THE OR: ,The patient was brought to the OR. Anesthesia was applied. The patient was given preoperative antibiotics. The patient was bowel prepped. The patient was placed in right side up, left side down, semiflank, with kidney rest up. All the pressure points are very well padded using foam and towels. The left knee was bent and the right knee was straight. There was no tension on any of the joints. All pressure points were well padded. The patient was taped to the table using 2-inch wide tape all the way around. A Foley catheter and OG tube were in place prior to prepping and draping the patient. A periumbilical incision measuring about 6 cm was made. The incision was carried through the subcutaneous tissue through the fascia using sharp dissection. The peritoneum was open. Abdomen was entered. There were some adhesions on the right side of the abdomen, which were released using metz. Two 12-mm ports were placed in the anteroaxillary line and one in the midclavicular line. A gel porter was placed. Pneumoperitoneum was obtained. All ports were placed under direct vision, and the right colon was reflected medially. Duodenum was cauterized. Minimal dissection was done on the hilum and the Gerota's was opened laterally, and the renal masses were clearly visualized all the way around. Pictures were taken. Superficial biopsies were taken of 2 renal lesions using 3 different probes. The 2 lesions were frozen. The 2 probes were 2.4 mm and the other one was 3.1 mm in diameter. So the R3.8 and R2.4 long probes were used. Freezing/thawing, two cycles were done. The temperatures were -131, -137, -150 and the freezing time was 5 and 10 minutes each and passive sign was done. The exact times or exact temperatures are on the chart. There was a nice ice ball with each freezing and with passive sign. The probes were removed.,The probes were placed directly percutaneously through the skin into the renal lesions.,After freezing/thawing, the probes were removed and to seal with Surgicel were placed. Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding. From the time the probes were removed, until the time the laparoscope was removed, was total of 30 minutes. So the masses were visualized for a total of 30 minutes without any pneumoperitoneum. Pneumoperitoneum was obtained again. Fibrin glue was placed over it just for precautionary measure. There was about a total of 100 mL of blood loss overall with the entire procedure. Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ. The kidney was kept in the left hand at all times. Careful attention was drawn to make sure that the probe was deep enough, at least 3.5 to 4 cm in, to get the medial aspect of the tumors frozen. The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions. At the end of the procedure, after freezing/thawing and putting the fibrin glue, Surgicel, and EndoSeal, the colon was reflected medially. Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel. Lap count was correct. Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions. No deeper biopsies were done to minimize the risk of bleeding. The 12-mm ports were closed using 0-Vicryl and the middle incision. The hand-port incision was closed using looped #1 PDS from both sides and was tied in the middle. Please note that the pneumoperitoneum was closed using 0-Vicryl in running fashion. After closing the abdomen, 4-0 Monocryl was used to close the skin and Dermabond was applied.,The patient was brought to recovery in a stable condition.
## 455 PREOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,3. Liver cyst.,PROCEDURES PERFORMED:,1. Laparoscopic cholecystectomy.,2. Excision of liver cyst.,ANESTHESIA: ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1. Gallbladder.,2. Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:, Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. Additionally, there was a notable liver cyst. The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy. The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods. She had had multiple attacks in the past of these complaints. She was discovered to have had right upper quadrant pain on examination. Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis. The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms. She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE: ,The patient was brought to the operative suite and placed in the supine position. The patient received preoperative antibiotics with Kefzol. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. The patient did undergo general endotracheal anesthesia. Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel. Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation. The abdomen was insufflated to 15 mmHg. After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder. Decision to proceed with laparoscopic cystectomy was decided. A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen. Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin. All ports were inserted with bladed 5 mm trocar then under direct visualization. After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder. Adhesions adjacent were taken down with a Maryland dissector. Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly. This helped to better delineate the cystic duct as well as the cystic artery. Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one. Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally. Utilizing endoscissors, the cystic duct and cystic artery were ligated. Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed. Electrocautery was used to stop any bleeding encountered along the way. The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen. No evidence of stones were visualized. Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port. This was sent off as an specimen, a gallstone was identified within the gallbladder. Next, utilizing copious amounts of irrigation, the abdomen was irrigated. A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver. This was also taken and sent off as specimen. The abdomen was then copiously irrigated until clear irrigation was identified. All laparoscopic ports were removed under direct visualization. The abdomen was de-insufflated. Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region. All incisions were then closed with #4-0 undyed Vicryl. Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures. The areas were cleaned and dried. Steri-Strips were placed. On the incisions, sterile dressing was applied. The patient tolerated the procedure well. She was extubated following procedure. She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation.
## 456 PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:, Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs. The patient has now begun to have comorbidities related to the obesity. The patient has attended our bariatric seminar and met with our dietician and psychologist. The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient. Consent was obtained. The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. A Foley catheter was placed for bladder decompression. All pressure points were carefully padded, and sequential compression devices were placed on the legs. The abdomen was prepped and draped in standard, sterile, surgical fashion. Marcaine was injected into the umbilicus.
## 457 PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS: ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis. She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. The procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones. After answering her questions, she wished to proceed and gave informed consent.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. She was positively identified and the correct surgical site and procedure reviewed. After successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,The infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created. The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg. A 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity. Upper abdominal anatomy was normal. Pelvic laparoscopy revealed bilaterally closed internal inguinal rings. Additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____. There was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region. Using these, the gallbladder was grasped and retraced cephalad. Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction. A small ductotomy was created. Reddick cholangiogram catheter was then placed within the duct and the balloon inflated. Continuous fluoroscopy was used to instill contrast material. This showed normal common bile duct which entered the duodenum without obstruction. There was no evidence of common bile duct stones. The cholangiogram catheter was removed. The duct was doubly clipped and divided. The artery was divided and cauterized. The gallbladder was taken out of the gallbladder fossa. It was then placed in Endocatch bag and left in the abdomen. Attention was then paid to the appendix. The appendix was identified and window was made in the mesoappendix at the base. This was amputated with an Endo-GIA stapler. The mesoappendix was divided with an Endo-GIA vascular stapler. This was placed in another Endocatch bag. The abdomen was then irrigated. Hemostasis was satisfactory. Both the appendix and gallbladder were removed and sent for pathology. All trocars were removed. The 12-mm port sites were closed with 2-0 PDS figure-of-eight fascial sutures. The umbilical skin was reapproximated with interrupted 5-0 Vicryl Rapide. The remaining skin incisions were closed with 5-0 Monocryl subcuticular suture. The skin was cleaned. Mastisol, Steri-Strips and band-aids were applied. The patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition.
## 458 PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,PROCEDURE: ,After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 3 other trocars were placed. The first was a 10/11 mm trocar in the upper midline position. The second was a 5 mm trocar placed in the anterior iliac spine. The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left. The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally. The duct was divided between the clips. The clips were carefully placed to avoid occluding the juncture with the common bile duct. The cystic artery was found medially and slightly posterior to the cystic duct. It was carefully dissected free from its surrounding tissues. A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. The artery was divided between the clips. The 2 midline port sites were injected with 5% Marcaine.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula. As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. The neck of the gallbladder was removed from the abdomen. Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture. All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. Dressings were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
## 459 PROCEDURE PERFORMED:, Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 3 other trocars were placed. The first was a 10/11 mm trocar in the upper midline position. The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine. The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left. The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder. The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips. Several attempts at passing the cholangiocatheter into the ductotomy were made. Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct. After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography. The distal cystic duct was doubly clipped. The duct was divided between the clips. The clips were carefully placed to avoid occluding the juncture with the common bile duct. The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly to the cystic duct. It was carefully dissected free from its surrounding tissues. A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. The artery was divided between the clips. The port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery. Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula. As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. The neck of the gallbladder was then secured with a Kocher clamp, and the gallbladder was removed from the abdomen.,Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture. All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. Dressings were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
## 460 PREOPERATIVE DIAGNOSIS:, Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS: ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS: ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion under general anesthesia. A curvilinear incision was made below the umbilicus. Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization. Once this complete, insufflation was begun. Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant. Once all four ports were placed, the right upper quadrant was then explored. The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis. This was taken down using Bovie cautery to free up visualization of the gallbladder. The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall. Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area. Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction. At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed. The cystic duct and cystic artery were serially clipped and transected. The gallbladder was removed from the gallbladder fossa removing the entire gallbladder. Adequate hemostasis with Bovie cautery was achieved. The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port. A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture. Next, the right upper quadrant was copiously irrigated out using the suction irrigator. Once this was complete, the additional ports were able to be removed. The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion. All skin incisions were injected using Marcaine 1/4 percent plain. The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique. The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.
## 461 PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS: ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1. Laparoscopic cholecystectomy.,2. Intraoperative cholangiogram.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted. Saline test was performed. Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg. The Veress needle was removed. A 10- to 11-mm cannula was inserted. Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it. It was largely mobile. The liver had a normal appearance as did the peritoneal cavity. A 5-mm cannula was inserted in the right upper quadrant anterior axillary line. A second 5-mm cannula was inserted in the subcostal space. A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction. The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal. Extra contrast was aspirated and the aspirating needle was removed. The ampulla was grasped with a second grasper, opening the triangle of Calot. The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided. This was done while the common duct was in full visualization. The cystic artery was similarly controlled and divided. The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution. There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula. The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear. Hemostasis was excellent. CO2 was evacuated and the camera removed. The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon. Sterile dressings were applied. Sponge and needle counts were correct.
## 462 PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS: ,Chronic cholecystitis.,PROCEDURE PERFORMED: ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION: ,To recovery room and to home.,FLUIDS: ,Crystalloid.,FINDINGS: , Consistent with chronic cholecystitis. Final pathology is pending.,INDICATIONS FOR THE PROCEDURE: ,Briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge. He presented now after informed consent for the above procedure.,PROCEDURE IN DETAIL: ,The patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia. The patient was correctly positioned, padded at all pressure points, had antiembolic TED hose and Flowtrons in the lower extremities. The anterior abdomen was then prepared and draped in a sterile fashion. Preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine. The initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with Bovie cautery, down to the midline fascia with a #15 scalpel blade. The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg. The epigastric and right subcostal trocars were placed under direct vision. The right upper quadrant was well visualized. The gallbladder was noted to be significantly distended with surrounding dense adhesions. The fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose Bovie dissector and the blunt Kittner peanut dissector. Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp. The cystic duct was clipped x3 and then divided. The cystic artery was dissected out in like fashion, clipped x3, and then divided. The gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip Bovie cautery with good hemostasis. Prior to removal of the gallbladder, all irrigation fluid was clear. No active bleeding or oozing was seen. All clips were noted to be secured and intact and in place. The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port. The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology. The camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization. The insufflation was allowed to escape. The umbilical fascia was closed using interrupted #1 Vicryl sutures. Finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 Monocryl. Sterile dressings were applied. The patient tolerated the procedure well.,
## 463 PREOPERATIVE DIAGNOSIS:, Cholelithiasis; possible choledocholithiasis.
## 464 PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:, Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY: ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks. The patient is also diabetic. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia. The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored. There was no evidence of any peritoneal studding or masses. The abdomen was otherwise within normal limits. The gallbladder was easily visualized. There was an intrahepatic gallbladder. There was no evidence of any inflammatory change.,PROCEDURE:, After informed written consent, the risks and benefits of the procedure were explained to the patient. The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion. Next, an infraumbilical incision was made with a #10 scalpel. The skin was elevated with towel clips and a Veress needle was inserted. The abdomen was then insufflated to 15 mmHg of pressure. The Veress needle was removed and a #10 blade trocar was inserted without difficulty. The laparoscope was then inserted through this #10 port and the abdomen was explored. There was no evidence of any peritoneal studding. The peritoneum was smooth. The gallbladder was intrahepatic somewhat. No evidence of any inflammatory change. There were no other abnormalities noted in the abdomen. Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty. The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization. The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder. Using a curved dissector, the cystic duct was identified and freed up circumferentially. Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct. The cystic artery was transected in similar fashion. Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip. It was done without difficulty. The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology. Hemostasis was maintained using electrobovie cautery. The liver bed was then copiously irrigated and aspirated. All the fluid and air was then aspirated and then all ports were removed under direct visualization. The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle. The skin was closed with a running subcuticular #4-0 undyed Vicryl. 0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was transferred to Recovery in stable condition.
## 465 The patient's abdomen was prepped and draped in the usual sterile fashion. A subumbilical skin incision was made. The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times. A subumbilical trocar was inserted. The camera was inserted in the panoramic view. The abdomen demonstrated some inflammation around the gallbladder. A 10-mm midepigastric trocar was inserted. A. 2 mm and 5 mm trocars were inserted. The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction. The cystic artery was identified and double Hemoclips applied. The gallbladder was taken down from the liver bed using Endoshears and electrocautery. Hemostasis was obtained. The gallbladder was removed from the midepigastric trocar site without difficulty. The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
## 466 PREOPERATIVE DIAGNOSIS: , Biliary colic.
## 467 PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute cholecystitis.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS: , None.,PROCEDURE: ,The patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position. The abdominal area was prepped and draped in the usual sterile fashion. A small skin incision was made below the umbilicus. It was carried down in the transverse direction on the side of her old incision. It was carried down to the fascia. An open pneumoperitoneum was created with Hasson technique. Three additional ports were placed in the usual fashion. The gallbladder was found to be acutely inflamed, distended, and with some necrotic areas. It was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips. The gallbladder was then taken down from the gallbladder fossa with electrocautery. There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie. The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones. The fascia had to be opened. The gallbladder had to be opened, and the stones had to be extracted carefully. When it was completed, I went back to the abdomen and achieved complete hemostasis. The ports were then removed under direct vision with the scope. The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl. All the incisions were injected with 0.25% Marcaine, closed with 4-0 Monocryl, Steri-Strips, and sterile dressing.,The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition.
## 468 PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS: ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced. The abdomen was prepped and draped and ports were placed. The gallbladder was grasped and retracted. The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained. The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag. The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak. The ports were removed under direct vision with good hemostasis. The Hasson was removed. The abdomen was desufflated. The gallbladder in its endo catch bag was removed. The ports were closed. The patient tolerated the procedure well. Please see full hospital dictation.
## 469 PREOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:, General.,FINDINGS:, The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a great deal of inflammatory reaction around the cystic duct. The cystic duct was slightly larger. There was a stone impacted in the cystic duct with the gallbladder. The gallbladder contained numerous stones which were small. With the stone impacted in the cystic duct, it was felt that probably none were within the common duct. Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:, Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully. Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. In this manner, the cystic duct and cystic artery were dissected out. Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. The gallbladder was then dissected free from the gallbladder bed. Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. The gallbladder was extracted through the operating trocar site, and the trocar was reinserted. Inspection was made of the gallbladder bed. One or two bleeding areas were fulgurated, and bleeding was well controlled.
## 470 PROCEDURE:,: After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced. The patient was then prepped and draped in the usual sterile fashion. An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline. The fascia was elevated between two Ochsner clamps and then incised. A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges. The 11-mm port without the trocar engaged was then placed into the abdomen. A pneumoperitoneum was established. After an adequate pneumoperitoneum had been established, the laparoscope was inserted. Three additional ports were placed all under direct vision. An 11-mm port was placed in the epigastric area. Two 5-mm ports were placed in the right upper quadrant. The patient was placed in reverse Trendelenburg position and slightly rotated to the left. The fundus of the gallbladder was retracted superiorly and laterally. The infundibulum was retracted inferiorly and laterally. Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder. The triangle of Calot was carefully opened up. The cystic duct was identified heading up into the base of the gallbladder. The cystic artery was also identified within the triangle of Calot. After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder. The cystic artery was clipped twice proximally and once distally. Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided. An intraoperative cholangiogram was obtained. This revealed good flow through the cystic duct and into the common bile duct. There was good flow into the duodenum without any filling defects. The hepatic radicals were clearly visualized. The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct. The cystic duct was then divided using scissors. The gallbladder was then removed up away from the liver bed using electrocautery. The gallbladder was easily removed through the epigastric port site. The liver bed was then irrigated and suctioned. All dissection areas were inspected. They were hemostatic. There was not any bile leakage. All clips were in place. The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry. All ports were then removed under direct vision. The abdominal cavity was allowed to deflate. The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl. The fascia at the umbilical port was closed by tying the previously placed stitch. All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites. The patient tolerated the procedure well. The patient is currently being aroused from general endotracheal anesthesia. I was present during the entire case.
## 471 PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants. The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed. No leakage of enteral contents was noted. All trocars were removed under direct visualization. The umbilical fascia was closed with interrupted 0 Vicryl sutures. The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's. The patient was extubated and taken to the recovery area in stable condition. The patient tolerated the procedure well.
## 472 PREOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Hypermenorrhea.,3. Mild pelvic endometriosis.,PROCEDURE PERFORMED:,1. Dilatation and curettage (D&C).,2. Laparoscopic ablation of endometrial implants.,ANESTHESIA: ,General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMEN: , Endometrial curettings.,INDICATIONS: , This is a 26-year-old female with a history of approximately one year of heavy painful menses. She did complain of some dyspareunia and wants a definitive diagnosis.,FINDINGS: , On bimanual exam, the uterus is small and anteverted with mildly decreased mobility on the left side. There are no adnexal masses appreciated. On laparoscopic exam, the uterus is normal appearing but slightly compressible. The bilateral tubes and ovaries appear normal. There is evidence of endometriosis on the left pelvic sidewall in the posterior cul-de-sac. There was no endometriosis in the right pelvic sidewall or along the bladder flap.,There were some adhesions on the right abdominal sidewall from the previous appendectomy. The liver margin, gallbladder, and bowel appeared normal. The uterus was sounded to 9 cm.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room and general anesthetic was administered. The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion. Sterile speculum was placed in the patient's vagina. The anterior lip of the cervix was grasped with vulsellum tenaculum. The uterus was sounded to 9 cm. The cervix was then serially dilated with Hank dilators. A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium. The moderate amount of tissue that was obtained was sent to Pathology. The #20 Hank dilator was then replaced and the sterile speculum was removed. Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made. The Veress needle was placed into this incision and the gas was turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. The #11 mm trocar was then placed through this incision and a camera was placed with the above findings noted. A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs. A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior. The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel. A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul-de-sac was removed to allow better visualization of the posterior cul-de-sac. The lesions in the posterior cul-de-sac were then ablated using the Harmonic scalpel. All instruments were then removed. The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar was removed. The skin was closed with #4-0 undyed Vicryl in subcuticular fashion. ,Approximately 10 cc of 0.25% Marcaine was placed in the incision sites. The dilator and vulsellum tenaculum were removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of procedure. The patient was taken to the recovery room in satisfactory condition. She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives.
## 473 PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis. She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table. The abdomen was prepared and draped in usual sterile fashion. After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made. A Veress needle was inserted. Abdomen was insufflated to 15 mmHg. A 5-mm port and camera placed. The abdomen was visually explored. There were no obvious abnormalities. A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two. Blunt dissection was used to isolate the appendix. Appendix was separated from surrounding structures. A window was created between the appendix and the mesoappendix. GIA stapler was tossed across it and fired. Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler. Appendix was placed in an Endobag and removed from the patient. Right lower quadrant was copiously irrigated. All irrigation fluids were removed. Hemostasis was verified. The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device. All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures. Steri-Strips and sterile dressings were applied. Overall, the patient tolerated this well, was awakened and returned to recovery in good condition.
## 474 PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1. Left adrenal mass, 5.5 cm.,2. Intraabdominal adhesions.,PROCEDURE PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:, None.,DISPOSITION:, The patient was taken to recovery room in stable condition. Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:, This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size. She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass. Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall. The spleen and liver were unremarkable. The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized. There was no evidence of peritoneal studding or masses. The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia. She was placed on a bean bag and secured to the table. The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed. Sterile drapes were applied. Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left. Laparoscopy was performed with ___________. At this point, we had a second trocar, which was 10 mm to 11 mm port. Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus. The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed. We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia. Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen. The colon was further mobilized medially again using gravity to aid in our retraction. After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland. We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected. There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected. Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis. Repeat laparoscopy showed no additional findings. The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding. The abdominal cavity was desufflated and was reinspected. There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture. At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated. The abdominal cavity was desufflated as stated. The patient was sent to Recovery in stable condition. Postoperative orders were written. The procedure was discussed with the patient's family at length.
## 475 PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1. Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3. Right L4-S1 posterolateral fusion with local bone graft.,4. Left L4 through S1 segmental pedicle screw instrumentation.,5. Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:, Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots. The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain. The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak. The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed. General anesthesia was induced. The patient was intubated. Foley catheter was in place. The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped. A previous incision was infiltrated with local and incised with a scalpel. The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala. Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone. The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting. The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints. Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed. Pars interarticularis were maintained. Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise. Pedicle screws were placed L4-L5 and S1 on the right side. Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe. It showed no penetration outside the pedicle vertebral body. At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed. Good bone purchase was obtained. Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1. Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots. Prior to placement of BMP, the wound was irrigated with antibiotic irrigation. Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision. Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl. Skin was stapled. The drain was sutured in place with 2-0 Vicryl and connected to closed drain system. The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition. The patient tolerated the procedure well without apparent complication. Final sponge and needle counts are correct. Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.
## 476 PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Ruptured appendicitis.,PROCEDURE:, Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:, This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers. The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's abdomen was prepped and draped in usual sterile fashion. A periumbilical incision was made. The fascia was incised. Peritoneal cavity entered bluntly. A 10-mm trocar and scope was passed. Peritoneal cavity was insufflated. Five-mm ports placed in left lower and hypogastric areas. On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus. We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site. We irrigated and suctioned out the right lower and pelvic areas. We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips. The patient was extubated in the operating table and taken back to recovery room. The patient tolerated the procedure well.
## 477 PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:, Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE: ,The patient was seen by me in the preoperative holding area. The risks of the procedure were explained. She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery. General anesthesia was carried out without difficulty and a Foley catheter was inserted. The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion. A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope. Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum. A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region. The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized. The base of the cecum was acutely inflamed but not perforated. I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix. The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty. I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty. I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty. I reinserted the suprapubic port and irrigated out the right lower quadrant until dry. One final inspection revealed no bleeding from the staple line. We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites. The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture. The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture. Steri-strips and sterile dressings were applied. No complications. Minimal blood loss. Specimen is the appendix. Brought to the recovery room in stable condition.
## 478 PREOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1. Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: ,Approximately 1000 cc.,CELL SAVER RETURNED: ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain. He had previous lumbar laminectomy at L4-L5. He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable. He is suffering from neurogenic claudication. He was unresponsive to extensive conservative treatment. He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia. He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded. His lumbar spine was then sterilely prepped and draped in the usual fashion. A previous midline incision was extended from approximate level of L3 to S1. This was in the midline. Skin and subcutaneous tissue were debrided sharply. Electrocautery provided hemostasis. ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia. The lumbar fascia was identified and split in the midline. Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1. Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4. Once this was completed, a self-retaining retractor was then placed. With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable. These were readily mobile with digital palpation. A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1. This bone was morcellized and placed on the back table for utilization for bone grafting. The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1. Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained. Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1. The microscope was utilized during this portion of procedure for visualization. There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure. Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5. Once this was identified, foraminotomies were created to allow additional mobility. The wound was then copiously irrigated with antibiotic solution and suctioned dry. Working type screws, provisional titanium screws were then placed at L4-l5. This was to allow distraction and reduction of the spondylolisthesis. These were placed in the pedicles of L4 and L5 under direct intensification. The position of the screws were visualized, both AP and lateral images. They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5. This allowed for additional decompression of the L5 and L4 nerve roots. Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed. Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval. This was taken in sequence up to a 13 mm space. This was then reduced to a 11 mm as it was much more anatomic in nature. Once this was completed, the spacers were then placed on the left side and distraction obtained. Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally. Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried. A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft. There were impacted at the interspace of L4-L5 under direct image intensification. Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried. The provisional screws and plates were removed. This allowed for additional compression along L4-L5 with the cage instrumentation. Permanent screws were then placed at L4, L5, and S1 bilaterally. This was performed under direct image intensification. The position was verified in both AP and lateral images. Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone. The wound was then copiously irrigated with antibiotic solution and suction dried. The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally. A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1. Appropriate cross connecters were applied and the construct was placed over the pedicle screws. They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra. Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory. All connections were tightened and retightened in Torque 2 specifications. The wound was then copiously irrigated with antibiotic solution and suction dried. The dura was inspected and noted to be free of tension. At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors. An 8-inch Hemovac drain was placed exiting the wound. The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin. The remainder of the Hemovac was assembled. Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape. He was turned and taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded.
## 479 PREOPERATIVE DIAGNOSIS:, Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS: ,Acute appendicitis with perforation.,ANESTHESIA:, General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis. A CT scan of his abdomen showed evidence of appendicitis with perforation. He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process. He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options. All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia. A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion. A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion. We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure. A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia. CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum. After these were gently separated, we began to identify the appendix. In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix. The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port. I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system. When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible. The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips. The patient tolerated the operation well. He was awakened and taken to the recovery room in satisfactory condition. His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure.
## 480 PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: ,The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. His abdomen was prepped and draped in a standard, sterile surgical fashion. A Foley catheter was placed for bladder decompression. Marcaine was injected into his umbilicus. A small incision was made. A Veress needle was introduced in his abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus. A 5-mm port was then placed just to the right side of the umbilicus. Another 5-mm port was placed just suprapubic in the midline. Upon inspection of the cecum, I was able find an inflamed and indurated appendix. I was able to clear the mesentery at the base of the appendix between the appendix and the cecum. I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix. I put the appendix in an Endocatch bag and removed it through the umbilicus. I irrigated out the abdomen. I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl. Sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications.
## 481 REASON FOR VISIT:, Lap band adjustment.,HISTORY OF PRESENT ILLNESS:, Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit. She was alert and oriented in no apparent distress. ,PROCEDURE: ,I was able to access her port. She does have an AP standard low profile. I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:, The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure. She will come back in two weeks for another adjustment as needed.,
## 482 PREOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1. Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2. Posterior cervical fusion C4-C5.,3. Songer wire.,4. Right iliac bone graft.,TECHNIQUE: ,The patient was brought to the operating room. Preoperative evaluations included previous cervical spine surgery. The patient initially had some relief; however, his left arm pain did recur and gradually got worse. Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6. There was also noted to be some annular bulges at C3-C4, and C6-C7. The CT scan in March revealed that the fusion was not fully solid. X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication. The patient had undergone several nonoperative treatments. He was given the option of surgical intervention. We discussed Botox, I discussed with the patient and posterior cervical decompression. I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery. If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion. The patient was a smoker and had been advised to quit smoking but has not quit smoking. I have therefore recommended that he use iliac bone graft. I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life. Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire. The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve. His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist. He still had some residual bursitis in his left shoulder and this would not be cured by this procedure. Other procedures may be necessary later. There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function. He could lose total control of his arms or legs and end up in the bed for the rest of his life. He could develop chronic regional pain syndromes. He could get difficulty swallowing or eating. He could have substantial weakness in the arm. He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks. He did not wish to get any other treatments. He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls. His head was controlled by a horseshoe holder. The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes. The arms, the right hip, and the neck was then prepped and draped. Care was taken to position both arms and both legs. Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine. A loupe magnification and headlamp illumination was used. Bleeding vessels were cauterized. Meticulous hemostasis was carried out throughout the procedure. Gradually and carefully I exposed the spinous process of the C6, C5, and C4. A lateral view was done after an instrument in place. This revealed the C6-C7 level. I therefore did a small laminotomy opening at C4-C5. I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5. I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left. I removed some of the superior lamina of C6 and some of the inferior lamina of C4. This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots. There was some bleeding from the epidural veins and a bipolar cautery was used. Absolutely no retractors were ever placed in the canal. There was no retraction. I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent. The nerve roots had been fully decompressed.,I then checked stability. There was micromotion at the C4-C5 level. I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5. I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4. Using a small drill, I opened the facet at C4-C5. I then used a very small curette to clean up the articular cartilage. I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped. An incision made over the iliac crest. Bleeding vessels were cauterized. I exposed just the posterior aspect of the crest. I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5. Drill holes made with a clip. I then packed cancellous bone between the decorticated spinous process. I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5. I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex. Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine. The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed. The patient was taken to the recovery room in good condition.
## 483 PREOPERATIVE DIAGNOSES: ,1. Fractured and retained lumbar subarachnoid spinal catheter.,2. Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES: ,1. L1 laminotomy.,2. Microdissection.,3. Retrieval of foreign body (retained lumbar spinal catheter).,4. Attempted insertion of new external lumbar drain.,5. Fluoroscopy.,ANESTHESIA: , General.,HISTORY: ,The patient had a lumbar subarachnoid drain placed yesterday. All went well with the surgery. The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina. The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE: ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls. Her face was resting in a pink foam headrest. Extreme care was taken positioning her because she weighs 92 kg. There was a lot of extra padding for her limbs and her limbs were positioned comfortably. The arms were not hyperextended. Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance. A Foley catheter was in place. She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked. It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina. The incision was carried down through the fascia all the way down to the spinous processes. A self-retaining McCullough retractor was placed. The laminae were quite deep. The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura. The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors. At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right. The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus. Microdissection under high magnification did not expose the catheter. The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle. Dr. Y also tried. Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned. It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus. The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura. The paraspinous muscles were closed with 0 Vicryl interrupted sutures. The subcutaneous fascia was also closed with 0 Vicryl interrupted suture. The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide. The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room. The patient tolerated procedure well. No complications. Sponge and needle counts correct. Blood loss minimal, none replaced. This procedure took 5 hours. This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.
## 484 PREOPERATIVE DIAGNOSES:,1. Pathologic insufficiency.,2. Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1. Pathologic insufficiency.,2. Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1. Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2. Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:, None.,SURGICAL INDICATIONS:, The patient is an 80-year-old female who had previous history of compression fractures. She had recently undergone an additional compression fracture of the T8 vertebrae. She was in extreme pain. This pain interfered with activities of daily living and was unimproved with conservative treatment modalities. She is understanding the risks, benefits, and potential complications as well as all treatment alternatives. The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table. She was given sedative. The thoracodorsal spine was then sterilely prepped and draped in the usual fashion. Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae. Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side. This was directly over the posterior aspect of the pedicle on the left. Once this was localized, the right side was localized as well. Stab incisions were then created over the pedicles of T8 bilaterally. Jamshidi needles were then placed percutaneously. Their position was verified in both AP and lateral images. They were advanced slowly under direct image intensification in biplanar fashion. Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae. The Jamshidi needles were then removed. A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae. This bone was then removed and sent to the lab. The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images. Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle. This was advanced under direct image intensification in a biplanar fashion. Once this was deemed satisfactory, it was impacted. The inner trocar was removed and a guidewire was then placed. An injection cannula was then placed over the guidewire into the body of T7. In a similar fashion, T9 was dressed on the left side as well. A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images. The cement injection cannula was then placed over this entering the T9 vertebrae body. Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae. The balloons were inserted bilaterally. The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg. These were allowed to expand and reduce the fracture. Once this was completed, the balloons were deflated and removed. The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas. This was done directly under image intensification. Once this was completed, additional cement was injected into T9 as there was a larger vertebra. The cement was allowed to cure. The cannula was removed and final radiographs were obtained. The stab incisions were then cleansed with water and antibiotic irrigation. The wounds were then approximated with #4-0 Nylon in interrupted fashion. Compression dressings were applied and fixed with tape. She was aroused and moved to her inpatient bed. She was moving all four extremities without deficit. She had no significant pain.
## 485 PREOPERATIVE DIAGNOSIS:, Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1. Dural tear, postoperative laminectomy, L4-L5.,2. Laterolisthesis, L4-L5.,3. Spinal instability, L4-L5.,OPERATIONS PERFORMED,1. Complete laminectomy, L4.,2. Complete laminectomy plus facetectomy, L3-L4 level.,3. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5. Posterior spinal fusion, L4 to S1.,6. Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS: ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago. He presented several days later with headaches as well as a draining wound. He was subsequently taken back for a dural repair. For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines. He has fullness in the back of his wound. The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak. The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:, After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7. The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties. The patient was given intraoperative antibiotics. The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level. Full-thickness skin flaps were developed. It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid. Cultures were taken, aerobic, anaerobic, AFB, fungal. Once this was done, the paraspinal muscles were affected from the posterior elements. It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1. It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis. Once this was done; however, the fluid emanating from the dura could not be seen appropriately. Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left. Complete laminectomy at L3 was done. Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen. Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture. A Valsalva confirmed no significant lead after the repair was made. There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation. The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl. After this the standard starting point was made. Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall. Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall. The screws were subsequently placed. Tricortical purchase was obtained at S1 ________ appropriate size screws. Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1. This was done on the right side first. The screw was torqued at S1 appropriately and subsequently at L5. Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4. Neutral compression distraction was obtained on the left side. Screws were torqued at L4, L5, and S1 appropriately. Good placement was seen both in AP and lateral planes using fluoroscopy. Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette. Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix. This was placed in the posterior lateral gutters. DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately. Deep retractors then removed from the confines of the wound. Fascia was closed using interrupted Prolene running suture #1. Once this was done, suprafascial drain was placed appropriately. Subcutaneous tissues were opposed using a 2-0 Prolene suture. The dermal edges were approximated using staples. Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape. The drain was connected appropriately. The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition. No complications arose.
## 486 PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:, Left patellar chondromalacia with tight lateral structures.,PROCEDURE:, Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: ,47 minutes.,MEDICATION: ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007. She was not seen in Orthopedic Clinic until November 2007. The patient had an outside MRI performed that demonstrated left patellar chondromalacia only. The patient was referred to physical therapy for patellar tracking exercises. She was also given a brace. The patient reported increasing pain with physical therapy and mother strongly desired other treatment. It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy. Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered. Risk and benefits of surgery were discussed. Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A nonsterile tourniquet was placed on the upper aspect of left thigh. The extremity was then prepped and draped in the standard surgical fashion. A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Esmarch was then removed. Incisions were then made. Camera was initially inserted into the lateral joint line. Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation. The patient did have congruent articulation about 30 degrees of knee flexion. Visualization of the medial joint line revealed no loose bodies. There was a small plica. Visualization of the medial joint line revealed no significant chondromalacia. Menisci was probed and tested with no signs of tears and instability. ACL was noted to be intact. The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology. Lateral gutter also demonstrated no loose bodies or plica. The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles. The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed. The patient had significant improvement in anteromedial translation from 25% to 50%. At the end of the case, all instruments were removed. The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine. Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case. The portals were then closed using 4-0 Monocryl. The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s. The kneecap was translated medially under pressure and a bias placed. The tourniquet was released at 47 minutes. The patient was then placed in the knee immobilizer. The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer. She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening. Intraoperative findings were relayed to the mother. All questions were answered.
## 487 PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:, Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA: ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology. The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded. Tourniquet was placed around the left upper thigh. The limb was then prepped and draped in usual sterile fashion. Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed. Patellofemoral joint showed frequent chondromalacia. Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus. The medial femoral condyle and medial tibial plateau were unaffected. Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus. The femoral condyle and tibial plateau were all stable to probing. Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors. A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry. 20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals. A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose. The patient was then transferred to the recovery room in stable condition.
## 488 PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:, Left medial compartment osteoarthritis of the knee.,PROCEDURE PERFORMED:, Left unicompartmental knee replacement.,COMPONENTS USED:, Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:, None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side. She has done quite well with this. She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table. After appropriate anesthesia, the left lower extremity was identified with a time out procedure. Preoperative antibiotics were given. Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet. The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used. Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed. The anterior fat pad was removed. The knee was then examined. The ACL was found to be intact. The lateral compartment had very minimal arthritis. There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild. Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place. Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection. Following this resection, the femoral intramedullary guide was placed without difficulty. The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide. Once in the appropriate position, it was pinned and drilled. This was removed, and the posterior cutting block was inserted. It was impacted into place. Posterior bone cut was made for the medium femoral component. Next, a zero spigot was used and the distal femur was reamed. Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well. Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit. Next, the tibia was prepared. The tibial tray was pinned into place, and the cuts for the keel of the tibia were made. These were removed with a small osteotome from the set. Following this, a trial tibial with the keel was placed and it did fit nicely. After this, all trial components were removed. The knee was copiously irrigated. Cement was begun mixing. Drill holes were used along the femur for cement interdigitation. The wound was cleaned and dried. Cement was placed on the tibia. Tibial tray was impacted into place. Excess cement was removed. Tibia was placed in the femur. Femoral component was impacted into place. Excess cement was removed. It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened. Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size. A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion. The intramedullary rod removed from the femur. The wound was irrigated with normal saline. The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin. A sterile dressing was placed. Tourniquet was then desufflated. Sponge and needle counts were correct at the end of the procedure. Dr. Jinnah was present for the surgery. The patient was transferred to the recovery room in stable condition. She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis. Prior to closure, the posterior capsule was injected with the joint cocktail.
## 489 PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee. This operative note will discuss the right total knee arthroplasty.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:, This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table. She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity. The right lower extremity was then sterilely prepped and draped in the usual fashion. An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg. Longitudinal incision was made over the anterior aspect of the right knee. Subcutaneous tissue was carefully dissected. A medial parapatellar retinacular incision was made. The patella was then everted and the above noted gross findings were appreciated. A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place. The appropriate cuts were made at the distal femur as well as with use of the chamfer guide. The trial femoral component was then positioned in place and noted to have good fit. Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut. The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments. The remnants of the anterior cruciate ligament and menisci were resected. The tibial trial was positioned in place. Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut. The tibial holes were then drilled. The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella. The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness. Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate. The knee was placed through range of motion with the trial components marked and then the appropriate components obtained. The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed. The femoral component was inserted with methylmethacrylate. Any excessive methylmethacrylate and bony debris were removed from the joint. Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm. The methylmethacrylate was also used at the patella. The prosthesis was positioned in place. The patellar clamp held securely till the methylmethacrylate was firm. After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment. This component was removed and revised to a stemmed component with better alignment and position. The previous component removed, the methylmethacrylate was removed. Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached. The trial tibial stemmed component was positioned in place. Knee was placed through range of motion and the tracking was better. Actual component was then obtained, methyl methacrylate was placed within the tibia. The stemmed tibial component was impacted into place with good fit. The Poly was then positioned in place. Knee held in full extension with compression longitudinally after methylmethacrylate was solidified. The trial Poly was removed. Wound was irrigated and the joint was inspected. There was no debris. Collateral ligaments and posterior cruciate ligaments remained intact. Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component. The tourniquet was deflated. Hemostasis was satisfactory. A drain was placed into the depths of the wound. The medial retinacular incision was closed with one Ethibond suture in interrupted fashion. The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain. The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion. The skin was closed with surgical clips. The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity. At the completion of the procedure, distal pulses were intact. Toes were pink, warm, with good capillary refill. Distal neurovascular status was intact. Postoperative x-ray demonstrated satisfactory alignment of the prosthesis. Prognosis is good in this 79-year-old female with a significant degenerative arthritis.
## 490 PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: , Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes. Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used. A NexGen femoral component with a distal femoral augmented block, size 5 mm. A NexGen tibial component, size 3 mm was used. A size 14 mm constrained polyethylene surface was used as well. Original patellar component that the patient had was maintained.,COMPLICATIONS: ,None.,BRIEF HISTORY:, The patient is a 68-year-old female with a history of knee pain for 13 years. She had previous total knee arthroplasty and revision at an outside facility. She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:, The patient was taken to the operative suite and placed on the operating table. Department of Anesthesia administered the spinal anesthetic. Once adequately anesthetized, the patient was placed in a supine position. Care was ensured and she was adequately secured and well padded in position. Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was inflated to approximately 325 mmHg on the right thigh. At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum. A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface. There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well. At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed. This was done without difficulty. Attention was then directed removing the femoral component. Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed. After this was performed, attention was then directed to the tibial component. An osteotome was again inserted around the surface and this was easily pried loose. There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation. This was evaluated. The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component. The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component. At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut. We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut. We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12. At this point, the distal femoral cutting guide based on the intramedullary head was then placed. Care was ensured that this was aligned in proper rotation with the external epicondylar axis. Once this was pinned in position, approximately a six degree valgus cut was then made. This allowed a portion of the medial condyle to be removed distally. The anterior cut was checked next using the intramedullary guide. The anterior surface cutting block was then placed. This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis. Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made. It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface. _______ was then removed and the chamfer cutting guide was then placed on. This allowed us to make a box cut and recut some of the angled cuts of the distal femur. Once this was placed and pinned in position. Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut. It was noted that the anterior chamfers did not need to be cut, take off no bone. The posterior chamfers did remove some bony aspects. This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component. After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed. This appeared to have an adequate fit and then packed in position. It appeared to be satisfactory. At this point, this was removed and attention was then directed to the tibia. The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained. At this point, the intramedullary guide was used to evaluate a tibial cut. This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface. The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component. At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone. This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component. This was placed in a proper position. A 10 mm articular surface was placed in the knee and this was taken through range of motion. This was found to have better alignment and satisfactory position. We elected to take an intraoperative x-ray at this point, to evaluate our cut. The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis. At this point, all trials were removed. The patella was then examined. The rongeur was used to remove the surrounding synovium. The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone. It was elected at this time to maintain this anatomic patella that was previously placed. At this point, the joint again was reevaluated and any bone loose fragments removed. There was noted to be some posterior tightness and mild osteophytes. These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes. Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried. The tourniquet was then reinflated. The canals were prepped for cementing. They were suction-dried and cleaned. The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial. Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component. The stemmed femoral component was then impacted in position and cemented. Again care was ensured that it was in adequate position and proper rotation. A size 14 mm poly was then inserted in between to provide compression. This was then taken through extension and held until cement cured. This was then removed and the components were evaluated. All excess cement was removed and they were well fixed. Size 14 mm trial Poly was then placed and this was taken through range of motion. This was found to have excellent range of motion and good stability. It was elected at this time that we would go with the size 14 mm Poly. This gave us extra Poly for ware and then provide excellent contact throughout the range of motion. The final articular surface was then placed and tightened into position to allow to _______ secured. The knee was then reduced and the knee was taken through range of motion. The patella was tracking with no-touch technique and adequately positioned. At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry. All bleeding was cauterized using a Bovie cautery. The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion. This was reinforced with a running #2-0 Vicryl. The knee was then flexed and noted that the patella was tracking with good alignment. The wound was again copiously irrigated and suctioned dry. A drain was placed prior to retinaculum repair deep to this to provide adequate drainage. At this point, the subcutaneous tissue was closed with #2-0 Vicryl. Skin was approximated with skin clips. Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed. A large Dupre dressing was then placed up the entire lower extremity. The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition.
## 491 PRE-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1. KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2. Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:, Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating. She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics. She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2. In addition to the fractures, she presents with kyphotic posture. Films on 1/04 demonstrated L1 and L2 osteoporotic fractures. Films on 2/04 demonstrated increased loss of height at L1. Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1. The L2 fracture is documented on radiographic studies as being chronic and a year or more old. The T12 fracture has the most significant kyphotic deformity. Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:, The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed. The patient was positioned prone on the Jackson table. The back was prepped and draped. The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker. In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate. An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side. Positioning was confirmed on the AP and lateral plane. Following satisfactory placement of the needle, the stylet was removed. A guide pin was inserted through the 11g to a point 3mm from the anterior cortex. AP and lateral images were taken to verify position and trajectory. Alongside of the guide pin a 1-cm paramedian incision was made. The needle was then removed leaving the guide pin in place. The osteointroducer was placed over the guide pin and advanced through the pedicle. Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall. Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel. The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex. After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex. The radiopaque marker bands on the bone tamp were identified using AP and lateral images. The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body. Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi. Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position. The inflation was monitored with AP and lateral imaging. The final balloon volume was 3.5 cc on the right side and 3 cc on the left. There was no breach of the lateral wall or anterior cortex of the vertebral body. Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved. Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement. The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side. Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12. An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved. Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures. The patient was kept in the prone position for approximately 10 minutes post cement injection. She was then turned supine, monitored briefly and returned to the floor. She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications. Estimated blood loss was minimal.
## 492 PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed in the operating room table in supine position and given general anesthetic.,Ancef 1 g was given for infectious prophylaxis. Once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion. Once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral. Through the lateral portal, the camera was placed. Through the medial portal, tools were placed. We proceeded to examine scarring of the patellofemoral joint. Then we probed the patellofemoral joint. A chondroplasty was performed using a shaver. Then we moved down to the lateral gutter. Some loose bodies were found using a shaver and dissection. We moved down the medial gutter. No plica was found.,We moved into the medial joint; we found that the medial meniscus was intact. We moved to the lateral joint and found that the lateral meniscus was intact. Pictures were taken. We drained the knee and washed out the knee with copious amounts of sterile saline solution. The instruments were removed. The 2 portals were closed using 3-0 nylon suture. Xeroform, 4 x 4s, Kerlix x2, and TED stocking were placed. The patient was successfully extubated and brought to the recovery room in stable condition. I then spoke with the family going over the case, postoperative instructions, and followup care.
## 493 TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY: ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy. Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death. This list was inclusive, but not exclusive. An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS: ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room. After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table. Lumbar spine was shaved, prepped, and draped in the usual sterile fashion. An incision was carried out from L4 to S1. Hemostasis was obtained with bipolar and Bovie cauterization. A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum. At this time, laminectomy was carried out of L5-S1. Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space. At this time, the disk was entered with a #15 blade and bipolar. The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk. We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root. Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic. At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound. There were no complications.
## 494 PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures. The incision was medial to and parallel to the extensor hallucis longus tendon. The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision. The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp. The surgical site was then flushed with saline. The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion. Site was dressed with a light compressive dressing. The tourniquet was released. Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:, None.,INJECTABLES:, Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:, Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well. Vital signs stable. Vascular status intact to all digits. Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s).
## 495 PREOPERATIVE DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,POSTOP DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,OPERATION AND PROCEDURE:,1. Left below-the-knee amputation.,2. Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:, 24 minutes on the left, 300 mmHg.,COMPLICATIONS:, None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well.
## 496 PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:, Exam under anesthesia. Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:, Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery. I was called for persistent bleeding and passing large clots. I examined the patient and found her to have at least 500 mL of clots in her uterus. She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her. I did advise her that I would recommend they came under anesthesia and dilation and curettage. Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed. She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion. Bimanual exam revealed moderate amount of clot in the uterus. I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed. I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found. At this point, the procedure was terminated. Bleeding at this time was minimal. Preop H&H were 8.3 and 24.2. The patient tolerated the procedure well and was taken to the recovery room in good condition.
## 497 PREOPERATIVE DIAGNOSIS: Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA: General endotracheal anesthesia.,OPERATIVE TIME: Three hours.,ANESTHESIA TIME: Four hours.,DESCRIPTION OF PROCEDURE: After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced. A Foley catheter was placed and a right internal jugular central line was placed. The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape. A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered. A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed. With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly. The small bowel was wrapped in moist green towel and retracted in the right upper quadrant. The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein. Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries. The mid left renal artery was likewise identified. The perirenal aorta was prepared for clamp superior to the inferior left renal artery. During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis. The distal dissection was then completed exposing each common iliac artery. The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time. The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps. The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery. The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed. There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site. The vessel was controlled with a microvascular clamp. Two pairs of lumbar arteries were oversewn with 2-0 silk. A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture. At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis. The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture. Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation. The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation. The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous. The colon was normal in appearance and this vessel was oversewn using 2-0 silk. The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion. The posterior peritoneum was reapproximated using running 3-0 PDS. The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera. The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location. The midline fascia was then reapproximated using running #1 PDS suture. The subcutaneous tissues were irrigated with bacitracin and kanamycin solution. The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.
## 498 PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME: ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient. The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position. All bony prominences were well padded at this time. At this time, Department of Anesthesia administered general anesthetic to the patient. The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left. The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time. The right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg. The patient was a consideration for a unicompartmental knee replacement. So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella. A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon. Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel. Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement. At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion. Total incision now measured approximately 25 cm. Retractors were placed. Next, attention was directed to establishing medial and lateral flaps of the proximal tibia. Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia. At this time, the patella was then everted. The knee was flexed up to 90 degrees. Next, using the large drill bit, the femoral canal was then opened in appropriate position. The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline. The guide was then removed. The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation. Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed. Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut. Upon checking, it was noted to be flat with no oscillations. The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus. It was secured in place using nails. The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position. Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws. Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut. A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well. The distal finishing guide was then removed and osteotome was then used to remove all resected bone. The oscillating saw was then used to complete the femoral notch cut. Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely. There was no posterior osteophytes noted and no fragments to the posterior aspect. Next, attention was directed towards the tibia. The external tibial guide was reflected. This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position. The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia. Next, collateral ligament retractors were placed as well as McGill retractors for the PCL. Oscillating saw was then used to make the proximal tibial cut. Osteotome was used to remove this excess resected bone. The laminar spreader was then used to check the flexion and extension. The gaps appeared to be equal. The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray. The knee was taken through range of motion and had very good flexion as well as full extension. There appeared to be good varus and valgus stability as well. Next, attention was directed towards the patella. There noted to be a sufficient ware and it was selected to replace the patella. It was sized with caliper, pre-cut and noted to be 26 mm depth. The sizing guide was then used and a size 51 resection guide selected. A 51 mm reamer was then placed and sufficient amount of patella was then removed. The calcar was then used to check again and there was noted to be 15 mm remaining. The 38 mm patella guide was then placed on the patella. It was noted to be in proper size and the three drill holes for the pegs were used. A trial component was then placed. The knee was taken through range of motion. There was noted to be some subluxation lateral to the patellar component and a lateral release was performed. After this, the component appeared to be tracking very well. There remained a good range of motion in the knee and extension as well as flexion. At this time, an AP x-ray of the knee was taken with the trial components in place. Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning. The knee was then copiously irrigated and dried. The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled. The knee again was copiously irrigated and suction dried. The final components were then selected again consisting of size F femoral components. A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella. Polymethyl methacrylate was then prepared at this time. The proximal tibia was dried and the cement was then pressed into place. The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning. Next, the proximal femur was cleaned and dried. Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components. This was then impacted in place as well. At this time, all excess cement was removed from both the tibial and femoral components. A size 12 mm trial tibial articular surface was then put in place. The knee was reduced and held in loading position throughout the remaining drying position of the cement. Next, the resected patella was cleaned and dried. The cement was placed on the patella as well as the backside of the patellar component. The component was then put in proper positioning and held in place with a clamp. All excess polymethyl methacrylate was removed from this area as well. This was held until the cement had hardened sufficiently. Next, the knee was examined. All excess cement was then removed. The knee was taken through range of motion with sufficient range of motion as well as stability. The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position. Again range of motion was noted to be sufficient. The knee was copiously irrigated and suction dried once again. A drain was then placed within the knee. The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl. The knee was again copiously irrigated and dried. The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin. The ConstaVac was then _______ to the drain. Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh. Department of Anesthesia then reversed the anesthetic. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications.
## 499 TITLE OF OPERATION: ,1. Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY: ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06. This was complicated by posterior capsule rupture. An intraocular lens implant was not attempted. He developed corneal edema and a preretinal hemorrhage. He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,POSTOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,ANESTHESIA: , General.,SPECIMEN: ,1. Donor corneal swab sent to Microbiology.,2. Donor corneal scar rim sent to Eye Pathology.,3. The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT: ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered. The patient was brought to the preoperative holding area, where the operative left eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced. The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye. A lid speculum was placed. The posterior segment infusion was placed by the vitreoretinal service. Peritomy was performed at the 3 and 9 o'clock limbal positions. A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion. The cornea was then measured and was found to accommodate a 7.5-mm trephine. The center of the cornea was marked. The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface. This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae. Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed. Corneoscleral scissors were then used to excise completely the central cornea. The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures. This was done without difficulty. At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note. At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service. The 9-0 Prolene sutures double armed were then placed on each lens haptic loop. The keratoprosthesis was removed. Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies. Wet-field cautery also was performed to achieve hemostasis. The leading hepatic sutures were then passed through the bed of the scleral flap. These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic. The trailing hepatic was then placed into the posterior segment of the eye as well. The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn. These were tied securely into position with the IOL nicely centered. At this point, the donor cornea punched at 8.25 mm was then brought into the field. This was secured with four cardinal sutures. The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture. The knot was secured and buried after adequate tension was adjusted. The corneal graft was watertight. Attention was then turned back to the IOL sutures, which were locked into position. The ends were trimmed. The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried. At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure. The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well. No complications were noted. The attending surgeon, Dr. X, performed the entire procedure. No complications of the procedure were noted. The intraocular lens was selected from preoperative calculations. No qualified resident was available to assist.
## 500 PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED: ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:, This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic. The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep. It appears to be right down to the bone. MRI shows findings suggestive of osteomyelitis. The patient is being brought to operating room for debridement of this ulcer. Procedure, indication, and risks were explained to the patient. Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped. Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer. This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base. The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone. The deeper portion of the excised tissue was also sent for tissue cultures. Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix. Sterile dressing was applied. The patient transferred to recovery room in stable condition.
## 501 TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY: ,The patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture. The patient was admitted and splinted and had compartment checks. The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia. The patient understood these risks and wished to proceed.,PREOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,POSTOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,ANESTHESIA: , General endotracheal.,INTRAVENOUS FLUID:, 900.,ESTIMATED BLOOD LOSS: ,100.,COMPLICATIONS:, None.,DISPOSITION: , Stable to PACU.,PROCEDURE DETAIL: ,The patient was met in the preoperative holding area and operative site was marked. The patient was brought to the operating room and given preoperative antibiotics. Left leg was then prepped and draped in the usual sterile fashion. A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue. The starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence. This was advanced and confirmed on the AP and lateral fluoroscopic images. The opening reamer was then used and the ball-tip guidewire was passed. The reduction was obtained over a large radiolucent triangle. After passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer. At this point, a 10 x 390 mm was passed without difficulty. The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws. The final images were taken with fluoroscopy and a 15-mm end-cap was placed. The wounds were then irrigated and closed with 2-0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2-0 Vicryl and staples to the proximal incision. The patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,The plan will be nonweightbearing left lower extremity. He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks.
## 502 PREOPERATIVE DIAGNOSIS:, Displaced left subtrochanteric femur fracture.,POSTOPERATIVE DIAGNOSIS:, Displaced left subtrochanteric femur fracture.,OPERATION: , Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,COMPLICATIONS:, None.,TOURNIQUET TIME:, None.,ESTIMATED BLOOD LOSS:, 50 mL.,ANESTHESIA: , General.,INDICATIONS: ,The patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities. She was diagnosed with displaced left subcapital hip fracture, now was asked to consult. With this diagnosis, she was indicated the above-noted procedure. This procedure as well as alternatives to this procedure was discussed at length with the patient and her son, who has the power of attorney, and they understood them well.,Risks and benefits were also discussed. Risks include bleeding, infection, damage to blood vessels, damage to nerves, risk of further surgery, chronic pain, restricted range of motion, risk of continued discomfort, risk of malunion, risk of nonunion, risk of need for further reconstructive procedures, risk of need for altered activities and altered gait, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. She understood these well and consented, and the son signed the consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on the operating table and general anesthesia was achieved. The patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment. External positions were felt to be present. At this point, the left hip and left lower extremity was then prepped and draped in the usual sterile manner. A guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire. An overlying drill was inserted to the proper depths. A Synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth. Proper rotation was obtained and the guide for the helical blade was inserted. A small incision was made for this as well. A guidewire was inserted and felt to be in proper position, in the posterior aspect of the femoral head, lateral, and the center position on AP. This placed the proper depths and lengths better. The outer cortex was enlarged and an 85-mm helical blade was attached to the proper depths and proper fixation was done. Appropriate size screw was then tightened down. At this point, a distal guide was then placed and drilled across both the cortices. Length was better. Appropriate size screw was then inserted. Proper size and fit of the distal screw was also noted. At this point, on fluoroscopic control, it was confirming in AP and lateral direction. We did a near anatomical alignment to the fracture site and all hardware was properly fixed. Proper size and fit was noted. Excellent bony approximation was noted. At this point, both wounds were thoroughly irrigated, hemostasis confirmed, and closure was then begun.,The fascial layers were then reapproximated using #1 Vicryl in a figure-of-eight manner, the subcutaneous tissues were reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated with staples. The area was then infiltrated with a mixture of a 0.25% Marcaine with Epinephrine and 1% plain lidocaine. Sterile dressing was then applied. No complication was encountered throughout the procedure. The patient tolerated the procedure well. The patient was taken to the recovery room in stable condition.
## 503 <NA>
## 504 PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:, Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair. The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right. The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced. The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:, After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion. An infraumbilical incision was made with a #15 Bard-Parker scalpel. The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty. Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg. Next, the Veress was removed and #10 bladed trocar was inserted without difficulty. The 30-degree camera laparoscope was then inserted and the abdomen was explored. There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible. Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus. Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization. A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization. Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral. The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty. Dissection was carried out, freeing up the hernia sac from the peritoneum. This was done without difficulty reducing the hernia in its entirety. Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract. The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples. This was done without difficulty. All three ports were removed under direct visualization. No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle. Skin was closed with running subcuticular #4-0 undyed Vicryl. Steri-Strips and sterile dressings were applied. Attention was next made to carrying out the circumcision. The foreskin was retracted back over the penis head. The desired amount of removing foreskin was marked out with a skin marker. The foreskin was then put on tension using a clamp to protect the penis head. A #15 blade scalpel was used to remove the foreskin and sending off as specimen. This was done without difficulty. Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially. This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing. The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition.
## 505 PREOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,PROCEDURE PERFORMED: ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia. The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time. He is slightly short of breath with mild difficulty in breathing. A pre-procedure x-ray was obtained, which showed no pneumothorax. He did have a significant right pleural effusion and a mild left pleural effusion. We decided to insert the catheter on the right side.,PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein. Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return. The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty. The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used. The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty. The guidewire was removed. Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty. The ports were flushed with injectable normal saline secondary to the patient going for dialysis today. Thus, he will not need heparinization of the lines. Again, he tolerated the procedure well. A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.
## 506 PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Care was taken not to injure the ilioinguinal nerve. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and sent to Pathology. The stump was examined and no bleeding was noted. The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring. In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
## 507 PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:, Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. Preoperative antibiotics were given for prophylaxis against surgical infection. The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle. This Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found. The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels. This was dissected back to the hernia opening. The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring. The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures. By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
## 508 PREOPERATIVE DIAGNOSIS:, Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia, direct.,PROCEDURE: , Left inguinal herniorrhaphy, modified Bassini.,DESCRIPTION OF PROCEDURE: ,The patient was electively taken to the operating room. In same day surgery, Dr. X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery. Informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion. Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened. The cord was isolated and protected. It was dissected out. The lipoma of the cord was removed and the sac was high ligated. The main hernia was a direct hernia due to weakness of the floor. A Bassini repair was performed. We used a number of interrupted sutures of 2-0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl. The dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.
## 509 PREOPERATIVE DIAGNOSIS: , Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia indirect.,ANESTHESIA: , Spinal with local.,COMPLICATIONS:, None.,DISPOSITION,: The patient tolerated the procedure well, was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,BRIEF HISTORY: , The patient is a 60-year-old female that presented to Dr. X's office with complaints of a bulge in the left groin. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a left indirect inguinal hernia.,PROCEDURE: , After informed consent was obtained, risks and benefits of the procedure were explained to the patient. The patient was brought to the operating suite. After spinal anesthesia and sedation given, the patient was prepped and draped in normal sterile fashion. In the area of the left inguinal region just superior to the left inguinal ligament tract, the skin was anesthetized with 0.25% Marcaine. Next, a skin incision was made with a #10 blade scalpel. Using Bovie electrocautery, dissection was carried down to Scarpa's fascia until the external oblique was noted. Along the side of the external oblique in the direction of the external ring, incision was made on both sides of the external oblique and then grasped with a hemostat. Next, the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament. Attention was next made to ligating the hernia sac at its base for removal. The hernia sac was opened prior grasping with hemostats. It was a sliding indirect hernia. The bowel contents were returned to abdomen using a #0 Vicryl stick tie pursestring suture at its base. The hernia sac was ligated and then cut above with the Metzenbaum scissors returning it to the abdomen. This was then sutured at the apex of the repair down to the conjoint tendon. Next, attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an #0 Vicryl suture and removed as specimen. Attention was next made to reapproximate it at floor with a modified ______ repair. Using a #2-0 Ethibond suture in simple interrupted fashion, the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia. Once this was done, the external oblique was closed over, reapproximated again with a #2-0 Ethibond suture catching each hump in between each repair from the prior floor repair. This was done in simple interrupted fashion as well. Next Scarpa's fascia was reapproximated with #3-0 Vicryl suture. The skin was closed with running subcuticular #4-0 undyed Vicryl suture. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure very well and he was transferred to Recovery in stable condition. The patient had an abnormal chest x-ray in preop and is going for a CT of the chest in Recovery.
## 510 PROCEDURE PERFORMED: , Inguinal herniorrhaphy.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel, and this incision was carried out to the external ring using Metzenbaum scissors. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle. This Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery. Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and went to Pathology. The ends of the suture were then cut and the stump retracted back into the abdomen.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 3-0 Vicryl in a running fashion, thus reforming the external ring. The skin incision was approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped and draped with benzoin, and Steri-Strips were applied. A dressing consisting of a 2 x 2 and OpSite was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
## 511 PREOPERATIVE DIAGNOSIS:, Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left direct and indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia with Prolene mesh.,ANESTHESIA: , IV sedation with local.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to Recovery in stable condition.,SPECIMEN: , Hernia sac, as well as turbid fluid with gram stain, which came back with no organisms from the hernia sac.,BRIEF HISTORY: ,This is a 53-year-old male who presented to Dr. Y's office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,INTRAOPERATIVE FINDINGS: , The patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac. The patient was also found to have some turbid fluid within the hernia sac, which was sent down for gram stain and turned out to be negative with no organisms.,PROCEDURE: , After informed consent, risks and benefits of the procedure were explained to the patient, the patient was brought to the operative suite, prepped and draped in the normal sterile fashion. The left inguinal ligament was identified from the pubic tubercle to the ASIS. Two fingerbreadths above the pubic tubercle, a transverse incision was made. First, the skin was anesthetized with 1% lidocaine and then an incision was made with a #15 blade scalpel, approximately 6 cm in length. Dissection was then carried down with electro Bovie cautery through Scarpa's fascia maintaining hemostasis. Once the external oblique was identified, external oblique was incised in the length of its fibers with a #15 blade scalpel. Metzenbaum scissors were then used to extend the incision in both directions opening up the external oblique down to the external ring. Next, the external oblique was grasped with Ochsner on both sides. The cord, cord structures as well as hernia sac were freed up circumferentially and a Penrose drain was placed around it. Next, the hernia sac was identified and the anteromedial portion of the hernia sac was stripped down, grasped with two hemostats. A Metzenbaum scissor was then used to open the hernia sac and the hernia sac was explored. There was some turbid fluid within the hernia sac, which was sent down for cultures. Gram stain was negative for organisms. Next, the hernia sac was to be ligated at its base and transected. A peon was used at the base. Metzenbaum scissor was used to cut the hernia sac and sending it off as a specimen. An #0 Vicryl stick suture was used with #0 Vicryl loop suture to suture ligate the hernia sac at its base.,Next, attention was made to placing a Prolene mesh to cover the floor. The mesh was sutured to the pubic tubercle medially along the ilioinguinal ligament inferiorly and along the conjoint tendon superiorly making a slit for the cord and cord structures. Attention was made to salvaging the ilioinguinal nerve, which was left above the repair of the mesh and below the external oblique once closed and appeared to be intact. Attention was next made after suturing the mesh with the #2-0 Polydek suture. The external oblique was then closed over the roof with a running #0 Vicryl suture, taking care not to strangulate the cord and to recreate the external ring. After injecting the external oblique and cord structures with Marcaine for anesthetic, the Scarpa's fascia was approximated with interrupted #3-0 Vicryl sutures. The skin was closed with a running subcuticular #4-0 undyed Vicryl suture. Steri-Strip with sterile dressings were applied.,The patient tolerated the procedure well and was transferred to Recovery in stable condition.
## 512 PREOPERATIVE DIAGNOSIS:, Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Right inguinal hernia.,ANESTHESIA: , General.,PROCEDURE: ,Right inguinal hernia repair.,INDICATIONS: , The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity. He had an inguinal hernia on physical exam in the Pediatric Surgery Clinic and is here now for elective repair. We met with his parents and explained the surgical technique, risks, and talked to them about trying to perform a diagnostic laparoscopic look at the contralateral side to rule out an occult hernia. All their questions have been answered and they agreed with the plan.,OPERATIVE FINDINGS: ,The patient had a well developed, but rather thin walled hernia sac on the right. The thinness of hernia sac made it difficult to safely cannulate through the sac for the laparoscopy. Therefore, high ligation was performed, and we aborted the plan for laparoscopic view of the left side.,DESCRIPTION OF PROCEDURE: , The patient came to operating room and had an uneventful induction of general anesthesia. Surgical time-out was conducted while we were preparing and draping his abdomen with chlorhexidine based prep solution. During our time-out, we reiterated the patient's name, medical record number, weight, allergies status, and planned operative procedure. I then infiltrated 0.25% Marcaine with dilute epinephrine in the soft tissues around the inguinal crease in the right lower abdomen chosen for hernia incision. An additional aliquot of Marcaine was injected deep to the external oblique fascia performing the ilioinguinal and iliohypogastric nerve block. A curvilinear incision was made with a scalpel and a combination of electrocautery and some blunt dissection and scissor dissection was used to clear the tissue layers through Scarpa fascia and expose the external oblique. After the oblique layers were opened, the cord structure were identified and elevated. The hernia sac was carefully separated from the spermatic cord structures and control of the sac was obtained. Dissection of the hernia sac back to the peritoneal reflection at the level of deep inguinal ring was performed. I attempted to gently pass a 3-mm trocar through the hernia sac, but it was rather difficult and I became fearful that the sac would be torn in proximal control and mass ligation would be less effective. I aborted the laparoscopic approach and performed a high ligation using transfixing and a simple mass ligature of 3-0 Vicryl. The excess sac was trimmed and the spermatic cord structures were replaced. The external oblique fascia and Scarpa layers were closed with interrupted 3-0 Vicryl and skin was closed with subcuticular 5-0 Monocryl and Steri-Strips. The patient tolerated the operation well. Blood loss was less than 5 mL. The hernia sac was submitted for specimen, and he was then taken to the recovery room in good condition.
## 513 PREOPERATIVE DIAGNOSIS: , Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct right inguinal hernia.,TITLE OF PROCEDURE: , Marlex repair of right inguinal hernia.,ANESTHESIA:, Spinal.,PROCEDURE IN DETAIL:, The patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic. The right inguinal region was shaved and prepped and draped in a routine sterile fashion. The patient received 1 gm of Ancef IV push.,Transverse incision was made in the intraabdominal crease and carried through skin and subcutaneous tissue. The external oblique fascia was exposed and incised down to and through the external inguinal ring. The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal. The cord was surrounded with a Penrose drain. The hernia sac was separated from the cord structures. The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene. Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord. It was placed around the cord and sutured to itself with 2-0 Prolene. The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper's ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene. The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief. The cord was returned to its position. External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips. Sponge and needle counts were correct. Sterile dressing was applied.
## 514 PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:, Right direct inguinal hernia. ,PROCEDURE:, Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:, General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was administered with endotracheal intubation. The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion. An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease. Dissection was taken down through the skin and subcutaneous tissue. Scarpa's fascia was divided, and the external ring was located. The external oblique was divided from the external ring up towards the anterior superior iliac spine. The cord structures were then encircled. Careful inspection of the cord structures did not reveal any indirect sac along the cord structures. I did, however, feel a direct sac with a direct defect. I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac. Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice. I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture. I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament. I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures. I then closed the external oblique with a running 3-0 Vicryl. I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril. Sponge, instrument and needle counts were correct at the end of the case. The patient tolerated the procedure well and without any complications.
## 515 PREOPERATIVE DIAGNOSIS:, Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Right inguinal hernia.,PROCEDURE:, Right inguinal hernia repair.,INDICATIONS FOR PROCEDURE: , This patient is a 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia. The patient is being taken to the operating room for inguinal hernia repair.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's inguinal and scrotal area were prepped and draped in the usual sterile fashion. An incision was made in the right inguinal skin crease. The incision was taken down to the level of the aponeurosis of the external oblique, which was incised up to the level of the external ring. The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed. The distal remnant was taken to its end and excised. The testicle and cord structures were placed back in their native positions. The aponeurosis of the external oblique was reapproximated with 3-0 Vicryl as well as the Scarpa's, the skin closed with 5-0 Monocryl and dressed with Steri-Strips. The patient was extubated in the operating room and taken back to the recovery room. The patient tolerated the procedure well.
## 516 PREOPERATIVE DIAGNOSIS:, Bilateral inguinal hernia. ,POSTOPERATIVE DIAGNOSIS: , Bilateral inguinal hernia. ,PROCEDURE: , Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation and the abdomen and groins were prepped and draped in standard, sterile surgical fashion. I did an ilioinguinal nerve block on both sides, injecting Marcaine 1 fingerbreadth anterior and 1 fingerbreadth superior to the anterior superior iliac spine on both sides.
## 517 PREOPERATIVE DIAGNOSES:, Bilateral inguinal hernia, bilateral hydroceles.,POSTOPERATIVE DIAGNOSES:, Bilateral inguinal hernia, bilateral hydroceles.,PROCEDURES: , Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 mL given.,ANESTHESIA: , General inhalational anesthetic.,ABNORMAL FINDINGS:, Same as above.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,FLUIDS RECEIVED: , 400 mL of Crystalloid.,DRAINS: , No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR PROCEDURE: ,The patient is a 7-year-old boy with the history of fairly sizeable right inguinal hernia and hydrocele, was found to have a second smaller one on evaluation with ultrasound and physical exam. Plan is for repair of both.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified. Once he was anesthetized, he was then placed in a supine position and sterilely prepped and draped. A right inguinal incision was then made with 15 blade knife and further extended with electrocautery down to the subcutaneous tissue and electrocautery was also used for hemostasis. The external oblique fascia was then visualized and incised with 15 blade knife and further extended with curved tenotomy scissors. Using a curved mosquito clamp, we gently dissected into the inguinal canal until we got the hernia sac and dissected it out of the canal. The cord structures were then dissected off the sac and then the sac itself was divided in the midline, twisted upon itself and suture ligated up at the peritoneal reflection with 3-0 Vicryl suture. This was done twice. The distal end where a large hydrocele noted, was gently milked into the lower aspect of the incision. The hydrocele sac was then opened and drained and then the testis was delivered into the field. The sac was then opened completely around the testis. The appendix testis was cauterized. We wrapped the sac around the back of the testis and tacked into place using the Lord maneuver using 4-0 Vicryl as a figure-of-eight suture. Once this was done, the testis was then placed back into the scrotum in the proper orientation. Ilioinguinal nerve block and wound instillation was then done with 10 mL of 0.25% Marcaine. A similar procedure was done on the left side, also finding a small hernia, which was divided and ligated with the 3-0 Vicryl as on the right side and distally the hydrocele sac was also wrapped around the back of the testis in a Lord maneuver after opening the sac completely. Again both testes were placed into the scrotum after the hydroceles were treated and then the external oblique fascia was closed on both sides with a running suture of 3-0 Vicryl ensuring that the ilioinguinal nerve and the cord structures not involved in the closure. Scarpa fascia was closed with 4-0 chromic suture on each side and the skin was closed with 4-0 Rapide subcuticular closure. Dermabond tissue adhesive was placed on both incisions. IV Toradol was given at the end of the procedure and both testes were well descended within the scrotum at the end of the procedure. The patient tolerated the procedure and was in stable condition upon transfer to the recovery room.
## 518 PREOPERATIVE DIAGNOSIS: ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE: ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. The fluid size tends to fluctuate with time but has been relatively persistent for the past year. I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options. All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS: ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum. We probably drained around 10 to 15 mL of fluid from the hydrocele sac. The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed. There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic. A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair. After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine. A curvilinear incision was made low in the left inguinal area along one of prominent skin folds. Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures. The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents. The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl. After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures. Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure. The patient tolerated the operation well. He was awakened and taken to the recovery room in good condition. Blood loss was minimal. No specimen was submitted.,
## 519 S - ,This patient has reoccurring ingrown infected toenails. He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing on the borders of the toes. One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe. These lesions measure 0.5 cm in diameter each. I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1. Onychocryptosis.,
## 520 PREOPERATIVE DIAGNOSES:, Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair, cerebral palsy, asthma, seizure disorder, developmental delay, and gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSES: , Left inguinal hernia, bilateral hydroceles, and right torsed appendix testis.,PROCEDURE: , Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.,FLUIDS RECEIVED: ,700 mL of crystalloid.,ESTIMATED BLOOD LOSS: ,10 mL.,SPECIMENS:, Tissue sent to pathology is calcified right appendix testis.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS: ,Sponge and needle counts were correct x2.,ANESTHESIA: , General inhalational anesthetic and 0.25% Marcaine ilioinguinal nerve block, 30 mL given per surgeon.,INDICATIONS FOR OPERATION: ,The patient is a 14-1/2-year-old boy with multiple medical problems, primarily due to cerebral palsy, asthma, seizures, gastroesophageal reflux disease, and developmental delay. He had a hernia repair done on the right in the past, but developed a new hernia on the right and a smaller on the left. The plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then placed in the supine position. IV antibiotics were given. He was then sterilely prepped and draped. A right inguinal incision was made in the previous incisional site with a 15-blade knife, extended down through the subcutaneous tissue and Scarpa fascia with electrocautery. Electrocautery was used for hemostasis.,The external oblique fascia was then visualized and incised. There was a moderate amount of scar tissue noted, but we were able to incise that and go down into the right inguinal canal. Upon dissection there, we did not find any hernias; however, he did have a fairly sizable hydrocele. We went down towards the external ring and found that this was indeed tight without any hernias.,We then closed up the external oblique fascia and made an incision after doing a shave on the right and left scrotum into the upper scrotal sac with a curvilinear incision with a 15-blade knife. We then extended down to the subcutaneous tissue. Electrocautery was used for hemostasis. The hydrocele sac was visualized and then drained after incising into it with a curved Metzenbaum scissors. The testis was then delivered and found to have a moderate amount of scar tissue with a calcified appendix testis, which was then excised and sent to pathology. We then checked the upper aspect of the tunica vaginalis pouch and found that there was indeed no other connection, was up above, so we then wrapped the sac around the back of the testis, and closed it with a 4-0 chromic suture in a Lord maneuver. We then closed the upper aspect of the subdartos pouch with a pursestring suture of 4-0 chromic and placed the testis into the scrotum in the proper orientation. We then used an ilioinguinal nerve block and wound instillation on both incisional areas with 0.25% Marcaine without epinephrine; 15 mL was given.,We performed a similar procedure on the left, incising it at the scrotal area first, rather than below, and found this tunica vaginalis, and dissected it in a similar fashion and cauterized the appendix testis, which was not torsed. This was a smaller hydrocele, but because of the __________ shunt, we went up above and found that there was a very small connection, which was then dissected off the cord structures gently, twisted upon itself, suture ligated with a 2-0 Vicryl suture.,The ilioinguinal nerve block and other wound instillations again with 15 mL total of 0.25% Marcaine were then done by the surgeon as well. The external oblique fascia was closed on both sides with a running suture of 2-0 Vicryl. 4-0 chromic was then used to close the Scarpa fascia. The skin was closed with a 4-0 Rapide subcuticular closure. The scrotal incisions were closed with a subcutaneous and dartos closure using 4-0 chromic. IV Toradol was given at the end of the procedure. Dermabond tissue adhesive was placed on all 4 incisions. The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.
## 521 PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE: ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion. The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail. The matrix was excised down to the bone and then the skin flap was placed over it. Hemostasis had been achieved with a cautery. A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well. Estimated blood loss was negligible. The patient was sent back to Same Day Surgery for recovery.
## 522 PREOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m. Nasal trachea intubation was performed per routine. The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report. Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft. Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft. Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine. Surgical team scrubbed and gowned in usual fashion and the patient was draped. Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa. A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion. Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region. The contents of the neurovascular canal from the greater palatine foramina were identified. The hard palate was directly observed. The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine. Similar features were reflected on the contralateral side. The area was re-contoured with rongeurs. The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable. A surgical mallet then compressed this bone further into the region. A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla. Particulate bone was then placed around the remaining block of bone. A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block. The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex. Attention was brought then to the mandible. 1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given. A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body. The anterior body was found to be approximately 3 mm in height. A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved. A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible. A similar procedure was done on the contralateral side. The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair. A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws. The block of bone was further re-contoured in situ. Particulate bone was then injected into the posterior tunnels bilaterally. A piece of AlloDerm was placed over those particulate segments. The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form. The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc. The estimated blood loss in the intraoral procedure was 220 cc. Total blood loss for the procedure 320 cc. The fluid administered 300 cc. The urine out 180. All sponges were counted encountered for as were sutures. The patient was taken to Recovery at approximately 12 o'clock noon.
## 523 PREOPERATIVE DIAGNOSIS: , Chronic renal failure.,POSTOPERATIVE DIAGNOSIS: ,Chronic renal failure.,PROCEDURE PERFORMED:, Insertion of left femoral circle-C catheter.,ANESTHESIA: , 1% lidocaine.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,HISTORY: , The patient is a 36-year-old African-American male presented to ABCD General Hospital on 08/30/2003 for evaluation of elevated temperature. He was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated. He did require a short-term of Levophed for hypotension. He is felt to have an infected dialysis catheter, which was removed. He was planned to undergo replacement of his Perm-A-Cath, dialysis catheter, however, this was not possible. He will still require a dialysis and will require at least a temporary dialysis catheter until which time a long-term indwelling catheter can be established for dialysis. He was explained the risks, benefits, and complications of the procedure previously. He gave us informed consent to proceed.,OPERATIVE PROCEDURE: , The patient was placed in the supine position. The left inguinal region was shaved. His left groin was then prepped and draped in normal sterile fashion with Betadine solution. Utilizing 1% lidocaine, the skin and subcutaneous tissue were anesthetized with 1% lidocaine. Under direct aspiration technique, the left femoral vein was cannulated. Next, utilizing an #18 gauge Cook needle, the left femoral vein was cannulated. Sutures were removed, nonpulsatile flow was observed and a Seldinger guidewire was inserted within the catheter. The needle was then removed. Utilizing #11 blade scalpel, a small skin incision was made adjacent to the catheter. Utilizing a #10 French dilator, the skin, subcutaneous tissue, and left femoral vein were dilated over the Seldinger guidewire. Dilator was removed and a preflushed circle-C 8 inch catheter was inserted over the Seldinger guidewire. The guidewire was retracted out from the blue distal port and grasped. The catheter was then placed in the left femoral vessel _______. This catheter was then fixed to the skin with #3-0 silk suture. A mesenteric dressing was then placed over the catheter site. The patient tolerated the procedure well. He was turned to the upright position without difficulty. He will undergo dialysis today per Nephrology.
## 524 DIAGNOSES,1. Term pregnancy.,2. Possible rupture of membranes, prolonged.,PROCEDURE:, Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:, The patient is a 20-year-old female, gravida 4, para 0, who presented to the office. She had small amount of leaking since last night. On exam, she was positive Nitrazine, no ferning was noted. On ultrasound, her AFI was about 4.7 cm. Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin. Once she was in her regular pattern, we ruptured her bag of water; fluid was clear. She went rapidly to completion over the next hour and a half. She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation. Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications. The baby was vigorous, moving all extremities. The cord was clamped and cut. The baby was handed off to mom with nurse present. Apgars were 8 and 9. Placenta was delivered spontaneously, intact. Three-vessel cord with no retained placenta. Estimated blood loss was about 150 mL. There were no tears.
## 525 PREOPERATIVE DIAGNOSIS:, Perirectal abscess.,POSTOPERATIVE DIAGNOSIS:, Perirectal abscess.,PROCEDURE: , Incision and drainage (I&D) of perirectal abscess.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room after obtaining an informed consent. A spinal anesthetic was given, and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion.,Prior to prepping, I performed a digital rectal examination that showed no pathology and then I proceeded to insert an anoscope. I found some small internal hemorrhoids and no fistulous tracts.,Then, the patient was prepped and draped in the usual fashion and the abscess area, which was in the left gluteal side, was incised with a cruciate incision and drained. All necrotic tissue was debrided. The cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area. The cavity was irrigated with saline and then was packed with iodoform gauze and dressed.,Estimated blood loss was minimal. The patient tolerated the procedure well and was sent for recovery in satisfactory condition.
## 526 PREOPERATIVE DIAGNOSIS: , Scalp lacerations.,POSTOPERATIVE DIAGNOSIS: , Scalp lacerations.,OPERATION PERFORMED: , Incision and drainage (I&D) with primary wound closure of scalp lacerations.,ANESTHESIA:, GET.,EBL: , Minimal.,COMPLICATIONS: , None.,DRAINS: , None.,DISPOSITION: , Vital signs stable and taken to the recovery room in a satisfactory condition.,INDICATION FOR PROCEDURE: ,The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. The patient was taken to the operating room for an I&D of the lacerations with wound closure.,PROCEDURE IN DETAIL: ,After appropriate consent was obtained from the patient, the patient was wheeled out to the operating theater room #5. Before the neck instrumentation was performed, the patient's lacerations to her scalp were I&D'ed and closed. It was noted that the head was significantly contaminated with blood as well as mangled. It was decided at that time in order to repair the lacerations appropriately, the patient would undergo cutting of her hair. This was shaved appropriately with shavers. Once this was done, the scalp lacerations were copiously irrigated with a scrubbing brush, hexedine solution together with peroxide. Once this was appropriately debrided with regards to the midline incision with the scalp going through the midline of her skull as well as the incision on the left aspect of her scalp, the wounds were significantly irrigated with normal saline. No significant debris was appreciated. Once this was done, staples were used to oppose the dermal edges together. The patient was subsequently dressed sterilely using bacitracin ointment, Xeroform, 4x4s, and tape. The neck procedure was subsequently performed.
## 527 TITLE OF OPERATION:,1. Irrigation and debridement of postoperative wound infection (CPT code 10180).,2. Removal of foreign body, deep (CPT code 28192).,3. Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL: ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei. He was admitted for a left wound breakdown with drainage. He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit. It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap. The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia. The patient understood these risks and wished to proceed. The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic. He was placed in the right lateral decubitus, and all bony prominences were well padded. An axillary roll was placed. A well-padded thigh tourniquet was placed on the left leg. The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement. Left leg was then prepped and draped in usual sterile fashion. The previous five antibiotic spacer beads were removed without difficulty. The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone. The wound actually looked quite good with evidence of purulence or drainage. Skin edges appeared to be viable. Hardware all looked to be intact. At this point, the wound was irrigated with 9 liters of bibiotic solution. A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint. The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure. He was immediately available for any questions during the case.,PLAN:,1. A CAM walker boots.,2. A VAC change on Sunday by the nurse.,3. A flap per Plastic Surgery.
## 528 PREOPERATIVE DIAGNOSIS: , Penoscrotal abscess.,POSTOPERATIVE DIAGNOSIS:, Penoscrotal abscess.,OPERATION: , Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.,BRIEF HISTORY: , The patient is a 75-year-old male presented with penoscrotal abscess. Options such as watchful waiting, drainage, and antibiotics were discussed. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, completely the infection turning into necrotizing fascitis, Fournier's gangrene were discussed. The patient already had significant phimotic changes and disfigurement of the penis. For further debridement the patient was told that his penis is not going to be viable, he may need a total or partial penectomy now or in the future. Risks of decreased penile sensation, pain, Foley, other unexpected issues were discussed. The patient understood all the complications and wanted to proceed with the procedure.,DETAIL OF THE OPERATION: ,The patient was brought to the OR. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in the usual fashion. Pictures were taken prior to starting the procedure for documentation. The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection. The penile area was opened up distally to allow the pus to come out. The dissection around the proximal scrotum was done to make sure there are no other pus pockets. The corporal body was intact, but the distal part of the corpora was completely eroded and had a fungating mass, which was biopsied and sent for permanent pathology analysis.,Urethra was identified at the distal tip, which was dilated and using 23-French cystoscope cystoscopy was done, which showed some urethral narrowing in the distal part of the urethra. The rest of the bladder appeared normal. The prostatic urethra was slightly enlarged. There are no stones or tumors inside the bladder. There were moderate trabeculations inside the bladder. Otherwise, the bladder and the urethra appeared normal. There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma. Again biopsies were sent for pathology analysis. Prior to urine irrigation anaerobic aerobic cultures were sent, irrigation with over 2 L of fluid was performed. After irrigation, packing was done with Kerlix. The patient was brought to recovery in a stable condition. Please note that 18-French Foley was kept in place. Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible, but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied. The patient was brought to Recovery in a stable condition after applying 0.5% Marcaine about 20 mL were injected around for local anesthesia.
## 529 PREOPERATIVE DIAGNOSIS: , Left neck abscess.,POSTOPERATIVE DIAGNOSIS: , Left neck abscess.,OPERATIVE PROCEDURE: , Incision and drainage of left neck abscess.,ANESTHESIA: ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to operating room and placed supine on the operating table. General inhalational anesthesia was administered. The patient was draped in usual fashion. The prominent area of the left submandibular swelling was noted and a 1-cm incision was outlined with a marking pen and the area was infiltrated with 0.5 mL of local anesthetic using 1% Xylocaine with epinephrine 1:100,000. The incision was performed with a #15 blade. An 18-gauge needle and 10 mL syringe was used to evacuate a small amount of the purulence from the abscess cavity. This was submitted for culture and sensitivity, anaerobic cultures and Gram stain. The cavity was opened with a small hemostat and a great deal of grossly purulent material was evacuated. The cavity was irrigated with peroxide and saline. A 0.25-inch Penrose drain was placed and secured with a single #3-0 nylon suture. A 4 x 4 dressing was applied. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
## 530 PREOPERATIVE DIAGNOSIS: ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2. Open reduction, right both bone forearm fracture with placement of long-arm cast.,COMPLICATIONS:, None.,TOURNIQUET: , None.,ESTIMATED BLOOD LOSS:, 25 mL.,ANESTHESIA: , General.,INDICATIONS: ,The patient suffered injury at which time he fell over a concrete bench. He landed mostly on the right arm. He noted some bleeding at the time of the injury and a small puncture wound. He was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,He was indicated the above-noted procedure. This procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well. Risks and benefits were also discussed. Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. They understood these well. All questions were answered and they signed the consent for procedure as described.,DESCRIPTION OF PROCEDURE: ,The patient was placed on the operating table and general anesthesia was achieved. The right forearm was inspected. There was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the middle one-third overlying the radial one-half. There was bleeding in this region. No gross contamination was seen. At this point, under fluoroscopic control, I did attempt to see a fracture. I was unable to do the forearm under the close reduction techniques. At this point, the right upper extremity was then prepped and draped in the usual sterile manner. An incision was made through the puncture wound site extending this proximally and distally. There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed. I also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed. These were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which I communicated through the puncture wound. Both ends were clearly visualized, and thorough irrigation was performed using total of 6 L of antibiotic solution. All nonviable gross contaminated tissue was removed. At this point with the bones in direct visualization, I did reduce the bony ends to anatomic alignment with excellent bony approximation. Proper alignment of tissue and angulation was confirmed.,At this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously. The ulna was now also noted to be in anatomic alignment.,At this point, the region was thoroughly irrigated. Hemostasis confirmed and closure then begun. The skin was reapproximated using 3-0 nylon suture. The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch Nugauze with iodoform. Sterile dressing applied and a long-arm cast with the forearm in neutral position was applied. X-ray with fluoroscopic evaluation was performed, which confirmed. They maintained excellent bony approximation and the anatomic alignment. The long-arm cast was then completely mature. No complications were encountered throughout the procedure. The patient tolerated the procedure well. The patient was then taken to the recovery room in stable condition.
## 531 PREOPERATIVE DIAGNOSES,1. Postoperative wound infection.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,POSTOPERATIVE DIAGNOSES,1. Postoperative wound infection. There was an intraperitoneal foreign body.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,PROCEDURES,1. Incision and drainage (I&D) of gluteal abscess.,2. Removal of pigtail catheter.,3. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was transferred to the operating room where a time-out process was followed. Under general endotracheal anesthesia, first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion. The opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward. I proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied.,Then, the patient was placed in a supine position, and I proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism. It came out without any difficulty. Then, the colostomy was protected and draped apart, and the patient's abdomen was prepped and draped in the usual fashion. My initial idea was to just drain and debride the wound infection, which had a sinus tract at lower end of the midline incision. I initially probed the wound with a hemostat and this had at least 12 cm long tract and I proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and I realized that the sinus tract was going through the fascia into the abdomen. Very carefully, I started dividing the fascia. Of course, there were several small bowel loops adhered to the area. The dissection was quite tedious for a while. Initially, I thought that may be there was an enterocutaneous fistula in the area, but then I realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract. I made a laparotomy of about 10 cm and I carefully dissected the bowel of the fascia. There was an area at the bottom which looked like a foreign body and initially I thought there was a mesh that can be used to close the abdomen, but later on this substance floated out by self and it was an elongated strip, maybe about 6 cm, which we sent to Pathology for examination. Initially, I have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms.,I was very happy that we were not really dealing with enterocutaneous fistula. The area was irrigated generously with saline and then we closed the fascia with number of interrupted figure-of-eight sutures of heavy PPS. The subcutaneous tissue and the skin were left open and packed with Betadine-soaked sponges.,A dressing was applied. A small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area. The patient tolerated the procedure well. Estimated blood loss was minimal, and he was sent to the ICU and also made acute care because of the need for a laparotomy, which we were not anticipating.
## 532 PREOPERATIVE DIAGNOSIS:, Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1. Incision and drainage, right foot.,2. Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:, An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap. General anesthesia was administered by the Department of Anesthesia. The foot was then prepped and draped in the usual sterile orthopedic fashion. The stockinette was reflected and the foot was cleansed with wet and dry sponge. There was noted to be some remaining periwound erythema. There was noted to be some mild crepitation about 2 cm proximal from the entry wound. The entry wound was noted to be over the third metatarsal head dorsally. Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound. The entry site from the foreign body was extended proximally approximately about 0.5 cm. At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body. Several small pieces were noted and they were removed. The area was palpated and there was no more remaining foreign body noted. At this time, the wound was inspected thoroughly. There was noted to be an area along the third metatarsal head more distally that did probe to the bone. There was no purulent drainage expressed. Area was flushed with copious amounts of sterile saline. Pulse lavage was performed with 3 liters of plain sterile saline. Wound cultures were obtained, aerobic and aerobic. The wound was then again inspected for any remaining foreign body or purulent drainage. None was noticed. The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact. The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry. The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.
## 533 PREOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1. Incision and drainage of right buccal space abscess.,2. Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1. Aerobic culture was sent from the right buccal space abscess/cellulitis.,2. Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13. The patient was intubated by anesthesia orotracheally using a #7 ET tube. The patient was induced in effective sleep using a propofol and gas inhalation anesthetics. Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack. At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area. Local infiltration also was done near the tooth #32. At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps. In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally. A hemostat was used to puncture through to the right buccal space. Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above. Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space. At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended. Note that the patient was extubated without incident. Dr. B was present for all critical aspects of patient care.
## 534 PREOPERATIVE DIAGNOSIS: , External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,POSTOPERATIVE DIAGNOSIS:, External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,PROCEDURES:,1. Placement of right external iliac artery catheter via left femoral approach.,2. Arteriography of the right iliac arteries.,3. Primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon.,3. Open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.,ANESTHESIA: , Local with intravenous sedation.,INDICATION FOR PROCEDURE:, He is a 67-year-old white male who is well known to me. He had severe peripheral vascular disease and recently underwent a kidney transplant. He has had some troubles with increasing serum creatinine and hypertension. Duplex suggests a high-grade iliac stenosis just proximal to his transplant kidney. He is brought to the operating room for arteriography and potential treatment of this.,DESCRIPTION OF PROCEDURE: , The patient was brought to operating room #14. A condom catheter was put in place. Preoperative antibiotics were administered. The patient's left arm was prepped and draped in the usual sterile fashion. An incision was made over his brachial artery after anesthetizing the skin. His brachial artery was dissected free and looped with vessel loops. Under direct vision, it was punctured with an 18-gauge needle and a short 3J guidewire and 6-French sheath put in place. A 3J guidewire was then introduced after the administration of intravenous heparin and advanced into the descending thoracic aorta. This was then advanced down into the right common iliac artery. The catheter was placed over this and arteriography performed. After adjusting the image intensifier to unfold the origin of the renal artery from the iliac system. We were able to demonstrate an approximately 60-70% stenosis of the external iliac artery. Immediately preceding the origin of the artery for the transplant kidney, which appeared to be widely patent. We elected to try and treat this. With catheter support a magic torque guidewire was advanced through the stenosis and into the common femoral artery. An 8 mm diameter x 3 cm length angioplasty balloon was positioned across the stenosis and inflated. This inflation was held for one minute. This was then deflated and a catheter positioned again in the proximal common iliac artery. For this application, we used a guide catheter that would allow us to inject contrast without losing our wire purchase. This showed an improvement in the stenosis, but a residual stenosis of at least 30% and we elected to stent this. An 8 mm diameter x 3 cm length stent was chosen and placed just proximal to the origin of the renal artery. After this was completed, the stent introduction balloon was removed and the catheter replaced. Repeat angiography showed a widely patent segment with no evidence of any residual stenosis. There was no evidence of any dissection or damage to the renal artery. We interpreted this as satisfactory procedure. Guidewires and sheaths were removed. The brachial artery was repaired with two interrupted sutures of 7-0 Prolene. The wound was irrigated and the subcutaneous tissue closed with a running suture of Vicryl. The skin was reapproximated with a running intracuticular suture of Monocryl. Steri-Strips and sterile occlusive dressing were applied and the patient was taken to the recovery room in stable condition. Estimated blood loss for the procedure was less than 50 mL. Total contrast employed was 37.5 mL. Total fluoroscopy time was 12 minutes and 43 seconds.
## 535 PREOPERATIVE DIAGNOSES:,1. Thickened endometrium and tamoxifen therapy.,2. Adnexal cyst.,POSTOPERATIVE DIAGNOSES:,1. Thickened endometrium and tamoxifen therapy.,2. Adnexal cyst.,3. Endometrial polyp.,4. Right ovarian cyst.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Hysteroscopy.,3. Laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:, None.,INDICATIONS: , This patient is a 44-year-old gravida 2, para 1-1-1-2 female who was diagnosed with breast cancer in December of 2002. She has subsequently been on tamoxifen. Ultrasound did show a thickened endometrial stripe as well as an adnexal cyst. The above procedures were therefore performed.,FINDINGS: ,On bimanual exam, the uterus was found to be slightly enlarged and anteverted. The external genitalia was normal. Hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium. Laparoscopic findings revealed a normal-appearing uterus and normal left ovary. There was no evidence of endometriosis on the ovaries bilaterally, the ovarian fossa, the cul-de-sac, or the vesicouterine peritoneum. There was a cyst on the right ovary which appeared simple in nature. The cyst was aspirated and the fluid was blood tinged. Therefore, the decision to perform oophorectomy was made. The liver margins appeared normal and there were no pelvic or abdominal adhesions noted. The polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped and placed in the dorsal lithotomy position. Her bladder was drained with a red Robinson catheter. A bimanual exam was performed, which revealed the above findings. A weighted speculum was then placed in the posterior vaginal vault in the 12 o'clock position and the cervix was grasped with vulsellum tenaculum. The cervix was then sounded in the anteverted position to 10 cm. The cervix was then serially dilated using Hank and Hegar dilators up to a Hank dilator of 20 and Hagar dilator of 10. The hysteroscope was then inserted and the above findings were noted. A sharp curette was then introduced and the 4 cm polyp was removed. The hysteroscope was then reinserted and the polyp was found to be completely removed at this point. The polyp was sent to Pathology for evaluation. The uterine elevator was then placed as a means to manipulate the uterus. The weighted speculum was removed. Gloves were changed. Attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made. While tenting up the abdominal wall, the Veress needle was inserted without difficulty. Using a sterile saline drop test, appropriate placement was confirmed. The abdomen was then insufflated with appropriate volume inflow of CO2. The #11 step trocar was placed without difficulty. The above findings were then visualized. A 5 mm port was placed 2 cm above the pubic symphysis. This was done under direct visualization and the grasper was inserted through this port for better visualization. A 12 mm port was then made in the right lateral aspect of the abdominal wall and the Endo-GIA was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament. Prior to this, the cyst was aspirated using 60 cc syringe on a needle. Approximately, 20 cc of blood-tinged fluid was obtained. After the ovary and fallopian tube were completely transected, this was placed in an EndoCatch bag and removed through the lateral port site. The incision was found to be hemostatic. The area was suction irrigated. After adequate inspection, the port sites were removed from the patient's abdomen and the abdomen was desufflated. The infraumbilical port site and laparoscope were also removed. The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips. 10 cc of 0.25% Marcaine was then injected locally. The patient tolerated the procedure well. The sponge, lap, and needle counts were correct x2. She will be followed up on an outpatient basis.
## 536 PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:, Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE: ,Under general anesthesia, skin was prepped and draped in usual fashion. Two incisions were made along the right buttock approximately 5 mm diameter. Purulent material was drained and irrigated with copious amounts of saline flush. A Penrose drain was placed. Penrose drain was ultimately sutured forming a circular drain. The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis. Anesthesia, general endotracheal anesthesia. Estimated blood loss approximately 5 mL. Intravenous fluids 100 mL. Tissue collected. Purulent material from buttock abscess sent for usual cultures and chemistries. Culture and sensitivity Gram stain. A single Penrose drain was placed and left in the patient. Dr. X attending surgeon was present throughout the entire procedure.
## 537 PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication. She had severe dyspareunia and chronic suprapelvic pain. The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process. Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain. She desired surgical treatment. She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs. The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa. Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon. Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind. Ureter visualized and palpated on right and appears normal. Indigo carmine given IV with no leaks intraperitoneally noted. Sigmoid colon dissected free from back of uterus and from cul-de-sac. Bowel free of lacerations or denudation. Upon inspection, right tube with hydrosalpinx, appendix absent. Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia. She was placed in a supine position with a transurethral Foley in place and compression stockings in place. The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum. The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs. Next, exploration of the abdominal and pelvic organs revealed the above noted findings. The uterus was enlarged and probably contained adenomyosis. There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within. The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus. A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges. Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel. Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb. The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder. The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted. Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed. The right round ligament was suture-ligated with 0 Polysorb. It was transected and divided with electrocautery. The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular. The left infundibulopelvic ligament was identified. It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted. Next, the uterine arteries were skeletonized on the right. They were transected and suture-ligated with 0 Polysorb. The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb. The cardinal ligaments were taken near their insertion into the cervical and uterine tissue. Pedicles were sharply developed and suture-ligated with 0 Polysorb. Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina. Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors. The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support. The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon. It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind. The right ureter was seen and palpated. It did not appear to be dilated and had good peristalsis noted. Next, the retractors were removed. The laparotomy sponges were removed from the abdomen. The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline. The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion. The skin was closed with 4-0 Polysorb in a subcuticular fashion. A thin layer of Dermabond was placed.,The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x 2. Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:, None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,
## 538 PREOPERATIVE DX:,1. Menorrhagia,2. Desires permanent sterilization.,POSTOPERATIVE DX:,1. Menorrhagia,2. Desires permanent sterilization.,OPERATIVE PROCEDURE:, Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.,ANESTHESIA: , General with paracervical block.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS:, On hysteroscopy, 100 ml deficit of lactated Ringer's via IV, 850 ml of lactated Ringer's.,COMPLICATIONS: , None.,PATHOLOGY: , None.,DISPOSITION: ,Stable to recovery room.,FINDINGS:, A nulliparous cervix without lesions. Uterine cavity sounding to 10 cm, normal appearing tubal ostia bilaterally, fluffy endometrium, normal appearing cavity without obvious polyps or fibroids.,PROCEDURE: , The patient was taken to the operating room, where general anesthesia was found to be adequate. She was prepped and draped in the usual sterile fashion. A speculum was placed into the vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.,The cervical vaginal junction at the 4 o'clock position was injected and 5 ml was instilled. The block was performed at 8 o'clock as well with 5 ml at 10 and 2 o'clock. The lidocaine was injected into the cervix. The cervix was minimally dilated with #17 Hanks dilator. The 5-mm 30-degree hysteroscope was then inserted under direct visualization using lactated Ringer's as a distention medium. The uterine cavity was viewed and the above normal findings were noted. The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia. The coil was advanced and easily placed and the device withdrawn. There were three coils into the uterine cavity after removal of the insertion device. The device was removed and reloaded. The advice was to advance under direct visualization and the tip was inserted into the left ostia. This passed easily and the device was inserted. It was removed easily and three coils again were into the uterine cavity. The hysteroscope was then removed and the ThermaChoice ablation was performed. The uterus was then sounded to 9.5 to 10 cm. The ThermaChoice balloon was primed and pressure was drawn to a negative 150. The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W. The pressure was brought up to 170 and the cycle was initiated. A full cycle of eight minutes was performed. At no time there was a significant loss of pressure from the catheter balloon. After the cycle was complete, the balloon was deflated and withdrawn. The tenaculum was withdrawn. No bleeding was noted. The patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.
## 539 PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:, Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:, None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma. She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X. It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters. Consent was obtained. The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted. A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression. She tolerated this procedure very well.
## 540 PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:, Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED: ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS: ,20 mL.,TUBES/DRAINS: ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: ,The patient is a 17-month-old boy with hypospadias abnormality. The plan is for repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. IV antibiotics were given. He was then placed in the supine position. The foreskin was retracted and cleansed. He was then sterilely prepped and draped. A stay stitch of 4-0 Prolene was then placed on the glans. The urethra was calibrated with the lacrimal duct probes to an 8-French. We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff. We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis. The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap. Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection. He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck. We repeated the artificial erection and the penis was straight. We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them. Using the curved iris scissors, we then also further mobilized the glanular wings. The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate. The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter. We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl. We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well. 5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans. Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans. Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff. On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place. IV Toradol was given at the procedure. The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.
## 541 PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:, Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:, General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy. She was counseled to undergo staging laparotomy.,FINDINGS:, Examination under anesthesia revealed a small uterus with no nodularity. During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease. Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal. There was no evidence of residual neoplasm after removal of the uterus. The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place. Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided. The peritoneum was entered without difficulty and washings were obtained. The abdomen was explored with findings as noted. A Bookwalter retractor was placed and bowel was packed. Clamps were placed on the broad ligament for traction. The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament. The round ligaments were isolated, divided, and ligated. The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters. The infundibulopelvic ligaments were isolated, divided, and doubly ligated. The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated. Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated. When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries. Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches. The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy. Metzenbaum scissors were used to incise lymphatic tissues. Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially. The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally. Ligaclips were applied where necessary. After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes. Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised. The pelvis was again irrigated and excellent hemostasis was noted. The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture. Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed. Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch. The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
## 542 1. Pelvic tumor.,2. Cystocele.,3. Rectocele.,POSTOPERATIVE DIAGNOSES:,1. Degenerated joint.,2. Uterine fibroid.,3. Cystocele.,4. Rectocele.,PROCEDURE PERFORMED: ,1. Total abdominal hysterectomy.,2. Bilateral salpingooophorectomy.,3. Repair of bladder laceration.,4. Appendectomy.,5. Marshall-Marchetti-Krantz cystourethropexy.,6. Posterior colpoperineoplasty.,GROSS FINDINGS: The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus. Curettings were negative for malignancy. The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy. The ovaries appeared to be within normal limits. There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized. No other pathology noted from the abdominal cavity or adhesions. The upper right quadrant of the abdomen compatible with a previous gallbladder surgery. The appendix is in its normal anatomic position. The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident. There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE: The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia. A midline incision was made around the umbilicus down to the lower abdomen. With a #10 Bard Parker blade knife, the incision was carried down through the fascia. The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors. A Balfour retractor was placed into the wound. This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care. The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture. The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus. The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament. An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered. After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus. The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture. After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak. Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply. The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture. The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors. A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors. The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect. The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture. The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision. The pelvis was irrigated with approximately 500 cc of water. The appendix was grasped with Babcock forceps. The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors. The curved hemostats were placed with #00 Vicryl suture. The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl. No bleeding was noted. Sponge, instrument, and needle counts were found to be correct. All packs and retractors were removed. The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture. Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples. Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands. An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors. The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally. In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture. Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture. The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture. The skin was closed with a running #000 plain gut subcuticular stitch. The vaginal vault was packed with a Betadine-soaked Kling gauze sponge. Sterile dressing was applied. The patient was sent to recovery room in stable condition.
## 543 PREOPERATIVE DIAGNOSES:, Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS: ,Uterine fragments.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty. The patient was placed in dorsal lithotomy position. Examination under anesthesia revealed an anteverted uterus and no adnexal masses. The patient was prepped and draped in normal sterile fashion. A Foley catheter was placed in the patient's bladder. The patient's cervix was visualized with speculum. A single-tooth tenaculum was placed on the anterior lip of the cervix. A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated. The tenaculum and speculum were then removed from the vagina. Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel. Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg. Veress needle was removed and then 5-mm trocar was placed through the umbilical incision. Laparoscope was placed through this incision and the patient's abdominal contents were visualized. A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope. A trocar incision was made in the right lower quadrant. A 10-mm trocar was placed through this incision under direct visualization with the laparoscope. A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope. The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe. The Gyrus cautery was used to cauterize and cut the right and left round ligaments. The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment. The right uteroovarian ligament was cauterized and cut using the Gyrus. The uterine vessels were then bluntly dissected. The Gyrus was then used to cauterize the right uterine vessels. Gyrus was then used on the left side to cauterize and cut the left round ligament. The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut. Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected. The left uterine vessels were then cauterized and cut using the Gyrus. At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching. At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels. The HUMI manipulator was removed prior to amputation of the uterine body. After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator. The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision. Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated. The Harmonic scalpel was used to cauterize the remaining endocervical canal. The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles. The Harmonic scalpel was then used to incise the right ovarian simple cyst. The right ovarian cyst was then drained yielding straw-colored fluid. The site of right ovarian cystotomy was noted to be hemostatic. The pelvis was again inspected and noted to be hemostatic. The ureters were identified on both sides and noted to be intact throughout the visualized course. All instruments were then removed from the patient's abdomen and the abdomen was deflated. The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion. The cervix was then visualized with the speculum. Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks. All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2. The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.
## 544 CHIEF COMPLAINT:, Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:, Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:, None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:, He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC: He denies any chest pain or shortness of breath.,GI: As noted above.,GU: As noted above.,ENDOCRINE: He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL: He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT: Unremarkable.,NECK: Supple. There is no mass, adenopathy, or bruit.,CHEST: Normal excursion.,LUNGS: Clear to auscultation and percussion.,COR: Regular. There is no S3, S4, or gallop. There is no murmur.,ABDOMEN: Soft. It is nontender. There is no mass or organomegaly.,GU: Unremarkable.,RECTAL: Deferred.,EXTREMITIES: His right lower extremity is unremarkable. Peripheral pulse is good. His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. There is one small area right essentially within the graft site, and there is one small area down lower on the calf area. The patient has an external fixation on that comes out laterally on his left thigh. Those pin sites look clean.,NEUROLOGIC: Without focal deficits. The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:, Plan would be for chemical cauterization of these areas. Series of treatment with chemical cauterization till these are closed.
## 545 PREOPERATIVE DIAGNOSIS:, Penoscrotal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Penoscrotal hypospadias with chordee.,PROCEDURE:, Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,ANESTHESIA: , General inhalation anesthetic with a caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , 15 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: , The patient is a 1-1/2-year-old boy with penoscrotal hypospadias; plan is for repair.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified. Once he was anesthetized, a caudal block was placed. IV antibiotic was given. The dorsal hood was retracted and the patient was then sterilely prepped and draped. A stay stitch of 4-0 Prolene was then placed in the glans for traction. His urethra was calibrated, it was quite thin, to a 10-French with the straight sounds. We then marked the coronal cuff and the urethral plate as well as the penile shaft skin with marking pen and incised the coronal cuff circumferentially and then around the urethral plate with the 15 blade knife and then degloved the penis with a curved tenotomy scissors. Electrocautery was used for hemostasis. The ventral chordee tissue was removed. We then placed a vessel loop tourniquet around the base of the penis and using IV grade saline did an artificial erection test, which showed that he had a persistent chordee. In the midline a 15 blade knife was used to incise Buck fascia after marking the area of chordee with the marking pen. We then used a Heinecke-Mikulicz Nesbit tuck with 5-0 Prolene to straighten the penis. Artificial erection again performed showed the penis was straight. The knot was buried with figure-of-eight suture of 7-0 Vicryl in Buck fascia above it. We then left the tourniquet in place and then after marking the urethral plate incised it and enlarged it with Beaver blade and a 15 blade. We then elevated the glanular wings as well in the similar fashion. An 8-French Zaontz catheter was then placed and the urethral plate was then closed over this with a distal interrupted sutures of 7-0 Vicryl and then a running subcuticular closure of 7-0 Vicryl to close the defect. We then put the stay sutures in the inter-preputial skin with 7-0 Vicryl and then rotated a flap using the subcutaneous tissue after dissecting it down to the pubis at the base of the penile shaft on the dorsum using the curved iris scissors. We buttonholed the flap and then placed it through the penis as a sleeve. Interrupted sutures of 7-0 Vicryl then used to reapproximate and to tack this flap and place over the urethroplasty. Once this was done, a two 5-0 Vicryl deep sutures were placed in the glans to rotate the glans and allow for hemostasis. Interrupted sutures of 7-0 Vicryl were then used to create the neomeatus and horizontal mattress sutures of 7-0 Vicryl used to reconstitute the glans. We then removed the excessive preputial skin and using tacking sutures of 6-0 chromic tacked the penile shaft skin to the coronal cuff and on the ventrum we dropped a portion of the skin down on the left side of the penis to reconstitute the penoscrotal junction using horizontal mattress sutures. We then closed the ventral defect. Once this was done, the stay suture in the glans was used to keep the Zaontz catheter to tack it into place. We then used Surgicel, Dermabond, and Telfa dressing with Mastisol and an eye tape to keep the dressing in place. IV Toradol was given at the end of the procedure. The patient was in stable condition upon transfer to the recovery room.
## 546 PREOPERATIVE DIAGNOSES:, Bladder cancer and left hydrocele.,POSTOPERATIVE DIAGNOSES: , Bladder cancer and left hydrocele.,OPERATION: ,Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,ANESTHESIA:, Spinal.,ESTIMATED BLOOD LOSS: ,Minimal.,FLUIDS:, Crystalloid.,BRIEF HISTORY: ,The patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected. He has received BCG. The patient is doing well. The patient was supposed to come to the OR for surveillance biopsy and pyelograms. The patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc. Options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed. The patient understood all the options and wanted to proceed with the procedure.,PROCEDURE IN DETAIL: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion.,A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn. The sac was turned upside down and sutures were placed. Careful attention was made to ensure that the cord was open. The testicle was in normal orientation throughout the entire procedure. The testicle was placed back into the scrotal sac and was pexed with 4-0 Vicryl to the outside dartos to ensure that there was no risk of torsion. Orchiopexy was done at 3 different locations. Hemostasis was obtained using electrocautery. The sac was closed using 4-0 Vicryl. The sac was turned upside down so that when it heals, the fluid would not recollect. The dartos was closed using 2-0 Vicryl and the skin was closed using 4-0 Monocryl and Dermabond was applied. Incision measured about 2 cm in size. Subsequently using ACMI cystoscope, a cystoscopy was performed. The urethra appeared normal. There was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder. There was a short prostatic fossa. The bladder appeared normal. There was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance. There were no papillary tumors or stones inside the bladder. Bilateral pyelograms were obtained using 8-French cone-tip catheter, which appeared normal. A cold cup biopsy of the bladder was done and was fulgurated for hemostasis. The patient tolerated the procedure well. The patient was brought to recovery at the end of the procedure after emptying the bladder.,The patient was given antibiotics and was told to take it easy. No heavy lifting, pushing, or pulling. Plan was to follow up in about 2 months.
## 547 PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION: ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. Finally, he has decided to have them get repaired. Plan is for surgical repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to the recovery room.
## 548 PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS: ,10 mL.,FLUIDS RECEIVED:, 300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee. Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified. Once he was anesthetized, IV antibiotics were given. The dorsal hood was retracted and cleansed. He was then sterilely prepped and draped. Stay suture of #4-0 Prolene was then placed in the glans. His urethra was calibrated to 10-French bougie-a-boule. We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum. Byers flaps were also marked. Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis. On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage. Once this was done, an electrocautery was used for hemostasis were then used. A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee. We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture. Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight. We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate. We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings. Using the curved iris scissors, we then elevated the wings even further. Again, electrocautery was used for hemostasis. An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture. There were two areas of coverage with the tissue flap relocation from the glanular wings. The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl. Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl. Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline. The extra dorsal hood tissue of preputial skin was then excised. An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline. The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself. At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing. Telfa and the surgical eye tape was then used for the final dressing. IV Toradol was given. The patient tolerated the procedure well and was in stable condition upon transfer to recovery room.
## 549 PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy. Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995. She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris. Biopsy obtained by The patient confirmed recurrence. In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris. No other obvious lesions were seen. The room was darkened and a Woods lamp was used to inspect the epithelium. A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen. The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm. Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum. After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized. Skin was incised with a scalpel and electrocautery was used to undermine. After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture. The final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was then taken to the Post Anesthesia Care Unit in stable condition.
## 550 PREOPERATIVE DIAGNOSIS:, Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia.,ANESTHESIA:, General; 0.25% Marcaine at trocar sites.,NAME OF OPERATION:, Laparoscopic left inguinal hernia repair.,PROCEDURE: , A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum. Insufflation and deinsufflation were done with the balloon removed. The structural balloon was placed in the preperitoneal space and insufflated to 10 mmHg carbon dioxide. The other trocars were placed in the lower midline times two. The hernia sac was easily identified and was well defined. It was dissected off the cord anteromedially. It was an indirect sac. It was taken back down and reduced into the peritoneal cavity. Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place. After this was completed, there was good hemostasis. The cord, structures, and vas were left intact. The trocars were removed. The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well.
## 551 PROCEDURE PERFORMED,1. Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2. Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:, After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered. Next, a #18-gauge needle was used to locate the subclavian vein. After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique. The needle was withdrawn. The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site. A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff. The catheter was cut to the appropriate length. A dilator and sheath were passed over the J wire. The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn. The catheter was flushed and aspirated without difficulty. The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy. A 2-0 nylon was used to secure the cuff down to the catheter at the skin level. The skin stab site was closed with a 4-0 Monocryl. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.
## 552 <NA>
## 553 PREOPERATIVE DIAGNOSIS: , Left hydrocele.,OPERATION: , Left hydrocelectomy.,POSTOPERATIVE DIAGNOSIS: , Left hydrocele.,ANESTHESIA: , General,INDICATIONS AND STUDIES: , This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum, approximately 8 cm. Laboratory data included a hematocrit of 43.5, hemoglobin of 15.0, and white count 4700. Creatinine 1.3, sodium 141, and potassium 4.0. Calcium 8.6. Chest x-ray was unremarkable. EKG was normal.,PROCEDURE: , The patient was satisfactorily given general anesthesia, prepped and draped in supine position, and left scrotal incision was made, carried down to the tunica vaginalis forming the hydrocele. This was dissected free from the scrotal wall back to the base of the testicle and then excised back to the spermatic cord. In the fashion, the hydrocele was excised and fluid drained.,Cord was infiltrated with 5 mL of 0.25% Marcaine. The edges of the tunica vaginalis adjacent to the spermatic cord were oversewn with interrupted 3-0 Vicryl sutures for hemostasis. The left testicle was replaced into the left scrotal compartment and affixed to the overlying Dartos fascia with a 3-0 Vicryl suture through the edge of the tunica vaginalis and the overlying Dartos fascia.,The left scrotal incision was closed, first closing the Dartos fascia with interrupted 3-0 Vicryl sutures. Skin was closed with an interrupted running 4-0 chromic suture. A sterile dressing was applied. The patient was sent to the recovery room in good condition, upon awakening from general anesthesia. Plan is to discharge the patient and see him back in the office in a week or 2 in followup. Further plans will depend upon how he does.
## 554 PRE AND POSTOPERATIVE DIAGNOSIS:, Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted. At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position. The patient's posterior cervical area was then prepped and draped in the usual sterile fashion. At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine. A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated. After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken. This showed the spinous process to be at the C4 level. Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified. After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken. This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time. At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina. The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe. This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur. However, progress was limited because of thickness of the bone. Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area. After the bone had been thinned out, further bone was removed using the Kerrison rongeur. At this point the nerve root was visually inspected and observed to be decompressed. However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade. Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery. After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin. Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches. The subcutaneous layer was then reapproximated using 000 Dexon. The skin was reapproximated using a running 000 nylon. Sterile dressings were applied. The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:, minimal.
## 555 PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF OPERATIVE PROCEDURE: , General endotracheal anesthesia was initiated without difficulty. The right arm, axilla, and chest wall were prepped and draped in sterile fashion. Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent. The draining veins are the deep brachial veins. The primary vein was carefully dissected out and small tributaries clamped, divided, and ligated with #3-0 Vicryl suture. A nice length of vein was obtained to the distal one third of the arm. This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein, which remains patent through a small collateral vein. A transverse skin incision was made over the superior aspect of the old fistula vein. This vein was carefully dissected out and encircled with vascular tapes. The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula. The patient was sensible, was then systemically heparinized. The existing fistula vein was clamped proximally and distally, incised longitudinally for about a centimeter. The brachial vein end was spatulated. Subsequently, a branchial vein to arterialized fistula vein anastomosis was then constructed using running #6-0 Prolene suture in routine fashion. After the completion of the anastomosis, the fistula vein was forebled and the branchial vein backbled. The anastomosis was completed. A nice thrill could be palpated over the outflow brachial vein. Hemostasis was noted. A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with #3-0 nylon suture. The wounds were then closed using interrupted #4-0 Vicryl and deep subcutaneous tissue ___ staples closed the skin. Sterile dressings were applied. The patient was then x-ray'd and taken to Recovery in satisfactory condition. Estimated blood loss 50 mL, drains 8 mm Blake. Operative complication none apparent, final sponge, needle, and instrument counts reported as correct.
## 556 TITLE OF OPERATION:, Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: , The patient is a patient well known to my service. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life. I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes. I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1. We went to the operating room at that time and we did a very large right-sided hemicraniectomy. The patient was put in the intensive care unit. We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago. Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk. We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift. At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________ this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room. She was already intubated and under general anesthesia. The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder. The patient tolerated this well. We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin. We connected this. Prior to this, we brought in all surgical instrumentation under sterile and standard conditions. We opened the skin as in opening a book and then we also did a myocutaneous flap. We brought in the muscle with it. We had a very good exposure of the skull. We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly. We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side. At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly. All this was irrigated thoroughly. Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely. We had absolutely good hemostasis. We put a piece of Gelfoam over the brain. We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position. I went ahead and irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place. This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely. Once we had done this, irrigated thoroughly once again the skin. We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit. The EBL was about 200 cubic centimeters. Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct. No complications. The patient went back to the intensive care unit.
## 557 PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:, Hemangioma, nasal tip.,PROCEDURE PERFORMED: ,1. Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2. Rhinoplasty.,ESTIMATED BLOOD LOSS: ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes.,CONDITION: ,Condition of the patient at end of the procedure stable, transferred to recovery room.,INDICATIONS FOR THE PROCEDURE: , The patient is a 2-year-old female with a history of a nasal tip hemangioma. The hemangioma has involved at her upper tongue. There has not been any change in the last 6 months. We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma. They understand the nature of the incision, the nature of the surgery, and the possibility of future revision surgeries. They understand the risk of bleeding, infection, dehiscence, scarring, need for future revision surgery, and minor asymmetry. They wished to proceed with surgery.,Because of the procedure, informed consent is obtained. The patient is taken to operating room and placed in the supine position. General anesthetic is administrated to an oroendotracheal tube. The face is prepped and draped in the usual manner. The incision is designed to the lower aspect of the hemangioma, which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions. The area is infiltrated with lidocaine with epinephrine. We waited 7 minutes for the hemostatic effect and proceeded with the incision. The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa, then extended laterally and upward to follow the lower lateral cartilage. This is done in both sides. Further incision is done. A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage, the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip. The hemangioma is removed and is found to be involving the medial aspects of both medial crura. This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion. Hemostasis is achieved with electrocautery. Then, we proceed to place some interdomal stitches with the help of a 6-0 clear nylon and intercrural stitches are placed and then an interdomal stitch, a single one was placed. The skin is redraped and the nose found to have satisfactory shape. The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella. Portions of skin and hemangioma are taken laterally on both sides of the columella distally. The skin was closed with 6-0 mild chromic stitches, including the portion at the level of the columella and rim incisions medially. The remaining of the internal incisions are closed with 5-0 chromic interrupted stitches. The nose is irrigated and suctioned. The patient tolerated the procedure without complications. I was present and participated in all aspects of the procedure. Sponge and instrument count were complete at the end of the procedure.
## 558 PROCEDURES,1. Left heart catheterization.,2. Coronary angiography.,3. Left ventriculogram.,PREPROCEDURE DIAGNOSIS:, Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,INDICATION: ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:, After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. He was prepped and draped in the usual sterile manner. The right inguinal area was anesthetized with 2% Xylocaine. A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique. JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively. Coronary angiographies were performed. These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle. Left ventriculography was performed. The patient tolerated the procedure well. At the end of the procedure, all catheters and sheaths were removed. The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE: ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL. Ejection fraction was calculated to be 69%. There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex. The LAD is small in caliber. In addition, there is a long bifurcating small-caliber diagonal branch noted. LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch. LCX and its branches are free of disease.,RCA:, RCA is a dominant small-caliber vessel with long small-caliber PDA branch. RCA and its branches are free of disease.,IMPRESSION,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain.
## 559 PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA: ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,HISTORY: ,The patient is an 86-year-old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08/30/03 after sustaining a fall at her friend's house. The patient states that she was knocked over by her friend's dog. She sustained a subcapital left hip fracture. Prior to admission, she lived alone in Terrano, was ambulating with a walker. All risks, benefits, and potential complications of the procedure were then discussed with the patient and informed consent was obtained.,HARDWARE SPECIFICATIONS: , A 28 mm medium head was used, a small cemented femoral stem was used, and a 28 x 46 cup was used.,PROCEDURE: ,All risks, benefits, and potential complications of the procedure were discussed with the patient, informed consent was obtained. She was then transferred from the preoperative care unit to operating suite #1. Department of Anesthesia administered spinal anesthetic without complications.,After this, the patient was transferred to the operating table and positioned. All bony prominences were well padded. She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards. The left lower extremity was then sterilely prepped and draped in the normal fashion. A skin maker was then used to mark all bony prominences. Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks. A #10 blade Bard-Parker scalpel was used to incise the skin through to the subcutaneous tissues. A second #10 blade was then used to incise through the subcutaneous tissue down to the fascia lata. This was then incised utilizing Metzenbaum scissors. This was taken down to the bursa, which was removed utilizing a rongeur. Utilizing a periosteal elevator as well as the sponge, the fat was then freed from the short external rotators of the left hip after these were placed and stretched. The sciatic nerve was then visualized and retracted utilizing a Richardson retractor. Bovie was used to remove the short external rotators from the greater trochanter, which revealed the joint capsule. The capsule was cleared and incised utilizing a T-shape incision. A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture. A cork screw was then used to remove the fractured femoral head, which was given to the scrub tech which was sized on the back table. All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur. Acetabulum was then inspected and found to be clear. Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut. An oscillating saw was then used to make the femoral cut. Box osteotome was then used to remove the bone from proximal femur. A Charnley awl was then used to open the femoral canal, paying close attention to keep the awl in the lateral position. Next, attention was turned to broaching. Initially, a small broach was placed, first making efforts to lateralize the broach then the femoral canal. It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate. Next, the trial components were inserted consisting of the above-mentioned component sizes. The hip was taken through range of motion and tested to adduction, internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip. It was noted that these size were stable through the range of motion. Next, the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal. The femoral component was then inserted and then held under pressure. Extruding cement was removed from the proximal femur. After the cement had fully hardened and dried, the head and cup were applied. The hip was subsequently reduced and taken again through range of motion, which was felt to be stable.,Next, the capsule was closed utilizing #1 Ethibond in figure-of-eight fashion. Next, the fascia lata was repaired utilizing a figure-of-eight Ethibond sutures. The most proximal region at the musculotendinous junction was repaired utilizing a running #1 Vicryl suture. The wound was then copiously irrigated again to suction dry. Next, the subcutaneous tissues were reapproximated using #2-0 Vicryl simple interrupted sutures. The skin was then reapproximated utilizing skin clips. Sterile dressing was applied consisting of Adaptic, 4x4s, ABDs as well as foam tape. The patient was then transferred from the operating table to the gurney. Leg lengths were checked, which were noted to be equal and abduction pillow was placed. The patient was then transferred to the Postoperative Care Unit in stable condition.
## 560 PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1. Right temporal lobe intracerebral hemorrhage.,2. Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1. Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2. Biopsy of dura.,3. Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:, Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently. This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today. She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe. There is significant mass effect. There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages. However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team. Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed. The patient was positioned supine with a three-point Mayfield head pin holder. Her scalp was prepped and draped in a sterile manner. Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly. The scalp was resected anteriorly. The subdural scar was noted, and hemostasis was achieved using Bovie cautery. The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety. The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected. It was quite full. The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur. The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax. The dura pack-up stitches were noted around the periphery from the previous craniotomy. This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure. Using a #15 blade, a new durotomy was then made. Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope. The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface. Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered. The parenchyma of the brain did not appear normal. It was quite vascular. Furthermore, there was a hematoma mixed in with the brain itself. Thus a core biopsy was then performed in the temporal tip. The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology. Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished. No attempt was made to enter into the sylvian fissure. Once hemostasis was meticulously achieved, the brain was inspected. It still was quite swollen, known that there was still hematoma in the parenchyma of the brain. However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed. DuraGen was then used for duraplasty because of the resected dura. The bone flap was then repositioned using Lorenz plating system. Then a medium Hemovac drain was placed in subdural space. Temporalis muscle was approximated using 2-0 Vicryl. The galea was then reapproximated using inverted 2-0 Vicryl. The scalp was then reapproximated using staples. The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly. The pupils are 3 mm bilaterally reactive to light. I accompanied her and transported her to the ICU where I signed out to the ICU attending.
## 561 PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration. A 6-French arterial sheath was placed in the usual fashion. Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic. The right coronary artery was difficult to cannulate because of its high anterior takeoff. This was nondominant. Several catheters were used. Ultimately, an AL1 diagnostic catheter was used. A pigtail catheter was advanced across the aortic valve. Left ventriculogram was then done in the RAO view using 30 mL of contrast. Pullback gradient was obtained across the aortic valve. Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results. There were no complications. He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1. Right coronary artery: This has an unusual high anterior takeoff. The vessel is nondominant, has diffuse mild-to-moderate disease.,2. Left main trunk: A 30% to 40% distal narrowing is present.,3. Left anterior descending: Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing. The diagonal is a large vessel about 3 mm in size.,4. Circumflex: Dominant vessel, 50% narrowing at the origin of the obtuse marginal. After this, there is 40% narrowing in the AV trunk. The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5. Left ventriculogram: Normal volume in diastole and systole. Normal systolic function is present. There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch. Dominant circumflex system. Severe disease of the posterior descending. Mild left main trunk disease.,2. Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery. The patient also has severe disease of the circumflex which is dominant. This anatomy is not appropriate for percutaneous intervention. The case will be reviewed with a cardiac surgeon.
## 562 PROCEDURE:, Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing. This was felt to be related largely to chronic obstructive lung disease. She had dynamic T-wave changes in precordial leads. Cardiac enzymes were indeterminate. She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail. The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory. Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped. Local anesthesia was obtained with 2% Xylocaine. The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel. Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed. Ascending aortic root pressures obtained. This catheter was utilized in an attempt to cannulate the left coronary ostium. This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta. The catheter appropriately aspirated and flushed. The catheter was advanced in the right coronary artery. Multiple views of that vessel were obtained. The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained. This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta. The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds. Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve. Videotapes were then reviewed. It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out. Excellent hemostasis was obtained. The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1. ,HEMODYNAMICS:, Left ventricular end-diastolic filling pressure was 24. There was no gradient across the aortic valve.,2. ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function. Mild inferobasilar hypokinesis was noted. No significant mitral regurgitation noted. Ejection fraction was estimated at 60%.,3. ,CORONARY ARTERIOGRAPHY,A. ,LEFT MAIN CORONARY: , The left main coronary was patent.,B. ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C. ,CIRCUMFLEX CORONARY ARTERY:, Circumflex coronary artery was occluded at its origin.,D. ,RIGHT CORONARY ARTERY,. Right coronary artery was occluded in its mid portion.,4. ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A. ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites. Excellent flow was noted in the diagonal system with some retrograde flow.,B. There was retrograde flow as well in the left anterior descending system.,C. ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:, Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites. There was no graft disease noted. Excellent flow was noted in the bifurcating marginal system.,D. ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:, Saphenous vein graft to right coronary was widely patent with no graft disease. Origin and insertion sites were free of disease. Distal flow in the graft to the posterior descending was normal.,5. ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites. There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel. Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1. Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.
## 563 PREOPERATIVE DIAGNOSIS: , Right colon tumor.,POSTOPERATIVE DIAGNOSES:,1. Right colon cancer.,2. Ascites.,3. Adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions.,3. Right hemicolectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,URINE OUTPUT: , 200 cc.,CRYSTALLOIDS GIVEN: , 2700 cc.,INDICATIONS FOR THIS PROCEDURE: ,The patient is a 53-year-old African-American female who presented with near obstructing lesion at the hepatic flexure. The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma. The patient was NG decompressed preoperatively and was prepared for surgery. The need for removal of the colon cancer was explained at length. The patient was agreeable to proceed with the surgery and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively. She was given triple antibiotics IV. Due to her near obstructive symptoms, a formal ________ was not performed.,The abdomen was prepped and draped in the usual sterile fashion. A midline laparotomy incision was made with a #10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia. Once divided, the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline. Extensive fluid was seen upon entering the abdomen, ascites fluid, which was clear straw-colored and this was sampled for cytology. Next, the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure, colonic mass, which was adherent to the surrounding tissues. With mobilization of the colon along the line of Toldt down to the right gutter, the entire ileocecal region up to the transverse colon was mobilized into the field. Next, a window was made 5 inches from the ileocecal valve and a GIA-75 was fired across the ileum. Next, a second GIA device was fired across the proximal transverse colon, just sparring the middle colic artery. The dissection was then carried down along the mesentry, down to the root of the mesentry. Several lymph nodes were sampled carefully, and small radiopaque clips were applied along the base of the mesentry. The mesentry vessels are hemostated and tied with #0-Vicryl suture sequentially, ligated in between. Once this specimen was submitted to pathology, the wound was inspected. There was no evidence of bleeding from any of the suture sites. Next, a side-by-side anastomosis was performed between the transverse colon and the terminal ileum. A third GIA-75 was fired side-by-side and GIA-55 was used to close the anastomosis. A patent anastomosis was palpated. The anastomosis was then protected with a #2-0 Vicryl #0-muscular suture. Next, the mesenteric root was closed with a running #0-Vicryl suture to prevent any chance of internal hernia. The suture sites were inspected and there was no evidence of leakage. Next, the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter. Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction. Next, the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia. Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples.,Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression.,
## 564 PREOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,PROCEDURE: ,The patient was taken to OR #2, administered general anesthetic. He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus. The left shoulder and upper extremities were then prepped and draped in the usual manner. A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus. This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery. Hemostasis was achieved with the cautery. The deltoid fascia were identified, skin flaps were then created. The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein. The deltoid was then retracted. There was marked hematoma and swelling within the subdeltoid bursa. This area was removed with rongeurs. The biceps tendon was identified which was the landmark for the rotator interval. Mayo scissors was utilized to split the remaining portion of the rotator interval. The greater tuberosity portion with the rotator cuff was identified. Excess bone was removed from the greater tuberosity side to allow for closure later. The lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,Excess bone was removed from the lesser tuberosity as well. Both of these were tagged with Ethibond sutures for later. The humeral head was delivered out of the wound. It was localized to the area of the anteroinferior glenoid region. The glenoid was then inspected, and noted to be intact. The fracture was at the level of the surgical neck on the proximal humerus. The canal was repaired with the broaches. An #8 stem was chosen as it was going to be cemented into place. The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion. Trial reduction was performed. The 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder. At this point, the wound was copiously irrigated with gentamycin solution. The canal was copiously irrigated as well and suctioned dry. Methyl methacrylate cement was mixed. The cement gun was filled and the canal was filled with the cement. The #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured. Excess cement was removed by sharp dissection. Prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later. Once the cement was cured, the modular head was impacted on to the Morse taper. It was stable and the shoulder was reduced. The lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant. The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well. The rotator interval was closed with #2 fiber wire in an interrupted fashion. The biceps tendon was ________ within this closure. The wound was copiously irrigated with gentamycin solution, suctioned dry. The deltoid fascia was then approximated with interrupted #2-0 Vicryl suture. Subcutaneous layer was approximated with interrupted #2-0 Vicryl and skin approximated with staples. Subcutaneous tissues were infiltrated with 0.25% Marcaine solution. A bulky dressing was applied to the wound followed by application of a large arm sling. Circulatory status was intact in the extremity at the completion of the case. The patient was then transferred to recovery room in apparent satisfactory condition.
## 565 PREOPERATIVE DIAGNOSES,1. Dyspnea on exertion with abnormal stress echocardiography.,2. Frequent PVCs.,3. Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2. Frequent PVCs.,3. Metabolic syndrome.,PROCEDURES,1. Left heart catheterization with left ventriculography.,2. Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state. Both groins were prepped and draped in the usual sterile fashion. Xylocaine 1% was used as local anesthetic. Versed and fentanyl were used for conscious sedation. Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique. Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter. Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter. Next, a #6-French angle pigtail catheter was advanced into the left ventricle. The left ventricular pressure was then recorded. Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds. The left heart pull back was then performed. The catheter was then removed.,Angiography of the right femoral artery was performed. Hemostasis was obtained by Angio-Seal closure device. The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1. LV pressure was 163/0 with end-diastolic pressure of 17. There was no significant gradient across the aortic valve.,2. Left ventriculography showed old inferior wall hypokinesis. Global left ventricular systolic function is normal. Estimated ejection fraction was 58%. There is no significant mitral regurgitation.,3. Significant coronary artery disease.,4. The left main is approximately 7 or 8 mm proximally. It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery. The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5. The left anterior descending artery is around 4 mm proximally. It extends slightly beyond the apex into the inferior wall. It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators. At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches. There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally. It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch. The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter. It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch. In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%. Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%. Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well. The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN: ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery. Continue risk factor modification, aspirin, and beta blocker.
## 566 PREOPERATIVE DIAGNOSES,1. Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2. Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3. Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation. He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:, Acute coronary artery syndrome with ST segment elevation in anterior wall distribution. Primary ventricular arrhythmia. Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent. Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:, Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE: ,The patient arrived from the emergency room intubated and ventilated. He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated. The right femoral area was prepped and draped in usual sterile fashion. Lidocaine 2 mL was then filled locally. The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath. A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained. A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized. An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent. An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained. It successfully re-canalized the artery. There is evidence of residual stenosis within the distal aspect of the previous stents. A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres. The intermittent result was improved. An additional inflation was obtained more proximally. His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation. There is patency of the left anterior descending artery and good antegrade flow. The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained. The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve. The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath. A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position. Cardiac catheter was determined by thermal dilution. The procedure was then concluded, well tolerated and without complications. The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring. Fluoroscopy time was 8.2 minutes. Total amount of contrast was 113 mL.,HEMODYNAMICS:, The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization. His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg. There was no gradient across the aortic valve. Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19. Cardiac output was 5.87 by thermal dilution.,CORONARIES:, On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A. Left main coronary: The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B. Left anterior descending artery: The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment. There is minimal collateral flow.,C. Circumflex: Circumflex is a nondominant circulation. It supplies a first obtuse marginal branch on good caliber. There is an outline of the stent in the midportion, which has mild 30% stenosis. The rest of the vessel has no significant obstructive lesions. It also supplies significant collaterals supplying the occluded right coronary artery.,D. Right coronary artery: The right coronary artery is a weekly dominant circulation. The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection. The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent. There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis. The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery. There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent. There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:, Integrilin infusion is maintained until tomorrow. He received aspirin and Plavix per nasogastric tube. Titrated doses of beta-blockers and ACE inhibitors are initiated. Additional revascularization therapy will be adjusted according to the clinical evaluation.
## 567 NAME OF PROCEDURE,1. Left heart catheterization with left ventriculography and selective coronary angiography.,2. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort. The patient had elevated troponins which were suggestive of a myocardial infarction. The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory. The patient was brought to the catheterization laboratory in postabsorptive state. The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region. Using modified Seldinger technique, a 6-French arterial sheath was placed. Then, the patient had already been on heparin. Then, a Judkins left 4 catheter was intubated into the left main coronary artery. Several projections were obtained and the catheter was removed. A 3DRC catheter was intubated into the right coronary artery. Several projections were obtained and the catheter was removed. Then, a 3DRC guiding catheter was intubated into the right coronary artery. Then, a universal wire was advanced across the lesion into the distal right coronary artery. Integrilin was given. Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds. Then, a projection was obtained. Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery. The stent was deployed at 15 atmospheres for 25 seconds. Post stent, the patient was given intracoronary nitroglycerin after one projection. Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful. Then, a pilot 150 wire was advanced across the lesion. Then, attempt to place the 2.0 x 8 power saver across the lesion was performed. However, it was felt that there was adequate flow and no further intervention needed to be performed. Then, the stent delivery system was removed. A pigtail catheter was placed into the left ventricle. Hemodynamics followed by left ventriculography was performed. Then, a pullback gradient was performed and the catheter was removed. Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied. The patient was transferred back to his room in good condition.,FINDINGS,1. Hemodynamics: The opening aortic pressure was 116/61 with a mean of 64. The opening left ventricular pressure was 112 with end-diastolic pressure of 23. LV pressure on pullback was 106 with end-diastolic pressure of 21. Aortic pressure was 111/67 with a mean of 87. The closing pressure was 110/67.,2. Left ventriculography: The left ventricle was of normal cavity, size, and wall thickness. There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis. The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%. The mitral valve had no significant prolapse or regurgitation. The aortic valve appeared to be trileaflet and moved normally.,3. Coronary angiography: The left main is a normal-caliber vessel. This bifurcates into the left anterior descending and circumflex arteries. The left main is free of any significant obstructive coronary artery disease. The left anterior descending is a large vessel that extends to the apex. It gives off approximately 10 septal perforators and 5 diagonal branches. The first diagonal branch was large. The left anterior descending had mild irregularities, but no high-grade disease. The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches. The two obtuse marginal branches are large. There is a relatively small left atrial branch. The left circumflex had a 50% stenosis after the first obtuse marginal branch. The rest of the vessel is moderately irregular, but no high-grade disease. The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches. The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease. However, distal between the second and third posterolateral branch, there is a 90% stenosis. The rest of the vessels had mild irregularities, but no high-grade disease. Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis. Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch. Then, a wire was advanced through this and there was improvement of flow. There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1. Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2. Two-vessel coronary artery disease.,3. Elevated left ventricular end-diastolic pressure.,4. Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1. Integrilin.,2. Bed rest.,3. Risk factor modification.,4. Thallium scintigraphy in approximately six weeks.
## 568 PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Saphenous vein graft angiography.,4. Left internal mammary artery angiography.,5. Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was then inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin and its pressure was held. The needle was removed over the guidewire. A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The catheter was then advanced into the left ventricle. The guidewire was then removed. The catheter was connected to the manifold and flushed. LVEDP was then measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material. LVEDP was then remeasured. Pullback was then performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was removed. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material. The saphenous vein graft was visualized in several different views. The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material. Right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was retracted. We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire. Next, a multipurpose catheter was advanced over the exchange wire. The wire was then easily passed into the left subclavian artery. The multipurpose catheter was then removed. LIMA catheter was then exchanged over the wire into the left subclavian artery. The guidewire was removed and the catheter was connected to the manifold and flushed. LIMA graft was then engaged using hand injections of non-ionic contrast material. The LIMA graft was evaluated in several different views. Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance. The sheath was flushed for the final time. The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection. There is no mitral regurgitation. There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart. There are luminal irregularities from the mid to distal portion. There is noted to be antegrade flow in the LIMA to LAD graft. There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove. There are minor luminal irregularities throughout. There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:, The RCA is a small vessel with luminal irregularities throughout. The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis. Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch. The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1. Diffusely diseased native vessels.,2. Saphenous vein graft to the obtuse marginal branch is widely patent.,3. Left internal mammary artery graft to the left anterior descending artery is patent.,4. Normal left ventricular function with ejection fraction of 60%.,5. Mildly elevated left-sided filling pressures.,PLAN:,1. The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix. The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2. We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3. Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4. The patient will need to be monitored closely for close lipid control as well as blood pressure control.
## 569 NAME OF PROCEDURES,1. Selective coronary angiography.,2. Left heart catheterization.,3. Left ventriculography.,PROCEDURE IN DETAIL: ,The right groin was sterilely prepped and draped in the usual fashion. The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed. Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg. A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery. Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed. This was advanced through the ostium of the left main coronary artery where selective angiograms were performed. Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed. A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram. The left heart pullback was performed. The catheter was removed and a small injection of contrast was given to the sheath. The sheath was removed over a wire and an Angio-Seal was placed. There were no complications. Total contrast media was 200 mL of Optiray 350. Fluoroscopy time 5.3 minutes. Total x-ray dose is 1783 mGy.,HEMODYNAMICS: ,Rhythm is sinus throughout the procedure. LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg. LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease. This also gives rise to the conus branch and two RV free wall branches. The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%. This vessel then bifurcates into the LAD and circumflex. The circumflex is a large caliber vessel and is dominant. This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA. There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity. The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity. The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic. The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal. Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall. The overall ejection fraction is preserved. There is moderate dilatation of the aortic root. The calculated ejection fraction is 63%.,IMPRESSION,1. Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2. Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery. There is subtotal stenosis at the origin of the first obtuse marginal artery.,3. A 60% stenosis in the distal circumflex.,4. Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.
## 570 PROCEDURE:, Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery. This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.,PROCEDURE DETAILS:, The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained. Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine. Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery. ACT was checked and was low. Additional heparin was given. A #6-French pigtail catheter was passed. Left ventriculography was performed. The catheter was exchanged for a #6-French JL4 catheter. Nitroglycerin was given in the left main. Left coronary angiography was performed. The catheter was exchanged for a #6-French __________ coronary catheter. Nitroglycerin was given in the right main, and right coronary angiography was performed. Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM. Considering his age and his course, it was elected to stent both these lesions. ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide. ReoPro was given in the RCA to prevent no reflow. A 0.014 Universal wire was passed. The lesion was measured. A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result. The catheter was removed and exchanged for a #6-French JL4 guide. The same wire was passed down the circumflex and the lesion measured. A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result. Plavix was given. The catheter was removed and sheath was in place. The results were explained to the patient and his wife.,FINDINGS,1. Hemodynamics. Please see attached sheet for details. ED was 20. There is no gradient across the aortic valve.,2. Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of diffuse, very minimal global hypokinesis. There is mild MR noted.,3. Coronary angiography.,a. Left main normal.,b. LAD. Some very minimal luminal irregularities. There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.,c. Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.,d. The RCA is large dominant and has a mid somewhat long 70% lesion.,4. Stenting.,a. The RCA revealed a lesion that went from 70% to a -5%.,B. The circumflex went from 95% to -5%.,CONCLUSION,1. Decreased left ventricular compliance.,2. Borderline normal overall ejection fraction with mild mitral regurgitation.,3. Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.,4. Successful stenting of the right coronary artery and the circumflex.,RECOMMENDATION: , ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors. I have ordered Zocor and a fasting lipid panel.,AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.
## 571 PROCEDURE: , Cardiac catheterization by:,a. Left heart catheterization.,b. Left ventriculography.,c. Selective coronary angiography.,d. Right femoral artery approach.,COMPLICATIONS:, None.,MEDICATIONS,1. IV Versed.,2. IV fentanyl.,3. Intravenous fluid administration.,4. Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained. Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed. The patient was prepped, draped, and anesthetized in the usual manner. Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery. Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections. Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections. Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance. Left ventricular angiogram was performed. Pre and post angiogram LVEDP, LV, and aortic pressures were obtained. At the end of the procedure catheters were removed and the introducer sheath was secured. The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:, LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal. The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall. Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction. No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1. ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch. Angiographically the right coronary artery is normal.,2. ,LEFT MAIN ARTERY:, The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3. ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex. Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging. The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment. Otherwise, there is no evidence of atherosclerotic obstruction.,4. ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex. Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery. These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome. The patient will be treated medically.
## 572 PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL: ,The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The right groin was prepped and draped, and infiltrated with 2% Xylocaine. Percutaneously, #6-French arterial sheath was placed. Selective native left and right coronary angiography was performed followed by left ventricular angiography. The patient had a totally occluded right coronary. We initially started with a JR4 guide. We were able to a sport wire through the total occlusion and saw a very tight stenosis. We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated. We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out. We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion. We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection. That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip. The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire. We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres. Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment. We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres. Final angiography showed resolution of the dissection. We could see a little staining extrinsic to the stent. No perforation and excellent flow. During the intervention, we did give a bolus and drip of Angiomax. At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix. We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop. We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:, Left main coronary is normal. Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal. The diagonal does appear to have about 50% osteal stenosis. There is a lot of plaquing further down the diagonal, but good flow. The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch. Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel. The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease. Some mild collaterals to the right were seen. Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin. After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve. Following the balloon angioplasty, we established good flow down the distal vessel. We still had about residual 70% stenosis. When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection. We re-dilated and then deployed. Repeat angiography now did show some hang up off dye distally. We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus. After deploying the stent, we had total resolution of the original lesion. We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA. The posterolateral branch appeared to be occluded in its mid portion. We got a wire through and dilated this. We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent. Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent. There were no filling defects in the stent and excellent flow. The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection. Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.
## 573 NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4. ,ANTICOAGULATION: ,The patient was on heparin at the time.,COMPLICATIONS: , None.,I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery. All questions were answered, and the patient desired to proceed.,HEMODYNAMIC DATA: ,Aortic pressure was in the physiologic range. No significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram: The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. Right coronary artery: Dominant. There was insignificant disease in the system.,3. Left coronary: Left main, left anterior descending and circumflex systems showed no significant disease.,CONCLUSIONS,1. Normal left ventricular systolic function.,2. Insignificant coronary disease.,PLAN: , Based upon this study, medical therapy is warranted. Six-French Angio-Seal was used in the groin.
## 574 CLINICAL INDICATION: ,Normal stress test.,PROCEDURES PERFORMED:,1. Left heart cath.,2. Selective coronary angiography.,3. LV gram.,4. Right femoral arteriogram.,5. Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure. The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion. After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery. Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters. Then, LV gram was performed using 6-French pigtail catheter. Post LV gram, LV-to-aortic gradient was obtained. Then, the right femoral arteriogram was performed. Then, the Mynx closure device was used for hemostasis. There were no complications.,HEMODYNAMICS: , LVEDP was 9. There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1. Left main is normal. It bifurcates into LAD and left circumflex.,2. Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present. Rest of the LAD free of disease.,3. Left circumflex is a large vessel and with minor plaque.,4. Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1. Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2. RCA has 40% proximal stenosis.,3. Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy. If the patient becomes symptomatic, we will repeat stress test. If there is ischemic event, the patient will need surgery for the LAD lesion. For the time being, we will continue with the medical therapy.,
## 575 PROCEDURE PERFORMED:,1. Right heart catheterization.,2. Left heart catheterization.,3. Left ventriculogram.,4. Aortogram.,5. Bilateral selective coronary angiography.,ANESTHESIA:, 1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:, The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. She has had atrial fibrillation and previous episodes of congestive heart failure. She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:, After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing. The patient was taken to the Cardiac Catheterization Lab where the procedure was performed. The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein. A guidewire was advanced into the lumen of the vein without resistance. The needle was removed and the guidewire was secured to the sterile field. The needle was flushed and then used to cannulate the right femoral artery. A guidewire was advanced through the lumen of the needle without resistance. A small nick was made in the skin and the needle was removed. This pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed. FiO2 sample was obtained and the sheath was flushed. An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed. A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated. An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to a manifold and flushed. Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured. Using dual transducers together and the mitral valve radius was estimated. The balloon was deflated and mixed venous sample was obtained. Hemodynamics were measured. The catheter was pulled back in to the pulmonary artery right ventricle and right atrium. The right atrial sample was obtained and was negative for shunt. The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material. Pullback was then performed which revealed a minimal LV-AO gradient. Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material. The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged. Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views. This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views. This catheter was removed. The sheaths were flushed final time. The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg. Pulmonary capillary wedge pressure is 29 mmHg. Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram. Cardiac index was 2.4 liters per minute/m2. Cardiac output 4.0 liters per minute. The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2. The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted. The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%. 2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted. There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long. It bifurcates into the LAD and left circumflex coronary artery. No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:, The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove. It tapers in its mid portion to become small caliber vessel. Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel. Small obtuse marginal branches are noted and this is the nondominant system. Lumen irregularities are present throughout the circumflex system. However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system. No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1. Nonobstructive coronary artery disease.,2. Severe mitral stenosis.,3. 2+ to 3+ mitral regurgitation.,4. 2+ to 3+ aortic insufficiency.
## 576 PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter. The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to manifold and flushed. The catheter did slip into the left ventricle. During the rotation, the LVEDP was then measured. The ostium of the right coronary artery was then engaged. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was then removed. The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally. The distal portion was diffusely diseased. The proximal portion otherwise shows minor luminal irregularities. The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY: ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch. The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion. The dominant coronary artery gives off the posterior descending artery and posterolateral artery. The left ventricular end-diastolic pressure was approximately 22 mmHg. It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1. Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2. Mildly elevated left-sided filling pressures.,PLAN:,1. The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting. These findings and plan were discussed in detail with the patient and the patient's family. The patient is agreeable.,2. The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy. The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting. In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.
## 577 NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:, Recurrent angina. History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:, 6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide. Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery. All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range. There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram: Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2. Right coronary artery: Dominant. There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3. Left coronary artery: The left main coronary artery showed insignificant disease. The circumflex arose, showed about 30% proximally. Left anterior descending arose and the previously placed stent was perfectly patent. There was a large diagonal branch which showed 90% stenosis in its proximal portion. There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery. He desired that we intervene.,Successful stenting of the left anterior descending, diagonal. The guide was placed in the left main. We easily crossed the lesion in the diagonal branch of the left anterior descending. We advanced, applied and post-dilated the 275 x 13 stent. Final angiography showed 0% residual at the site of previous 90% stenosis. The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1. Successful stenting of the left anterior descending/diagonal. Initially there was 90% in the diagonal after stenting. There was 0% residual. There was a lesion a bit more proximal in the 40% range.,2. Left anterior descending stent remains patent.,3. 30% in the circumflex.,4. 60% in the right coronary.,5. Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion. The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy. We used 6-French Angio-Seal in the groin. All questions have been answered. I have discussed the possibility of restenosis, need for further procedures.
## 578 INDICATION:, Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Right heart catheterization.,3. Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure. The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion. After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein. Then right heart cath was performed using 7-French Swan-Ganz catheter. Catheter was placed in the pulmonary capillary wedge position. Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained. The right heart catheter _______ pulled out. Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter. Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful. After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure. The patient tolerated the procedure well. There were no complications.,HEMODYNAMICS:,1. Cardiac output was 4.9 per liter per minute. Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2. Coronary angiography, left main is calcified _______ dense complex.,3. LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis. Left circumflex has diffuse luminal irregularities. OM1 has 70% stenosis, is a moderate-size vessel. Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery.
## 579 PROCEDURE PERFORMED:, Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing. The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein. A steel guidewire was then inserted through the needle into the vessel without resistance. Small nick was then made in the skin and the needle was removed. An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated. Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position. Hemodynamics were measured along the way. Pulmonary artery saturation was obtained. The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration. The patient tolerated the procedure well. The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:, Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula. Pulmonary artery saturation equals 37.8. Pulse oximetry on 2 liters nasal cannula equals 93%. Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION: ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor. The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia. At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy. We will also increase his Lasix to 80 mg IV q.d. We will increase his amiodarone to 400 mg daily. We will also continue with his Coumadin therapy. As stated previously, we will discontinue vasodilator therapy starting with the Isordil.
## 580 TITLE OF OPERATION:,1. Removal of painful hardware, first left metatarsal.,2. Excision of nonunion, first left metatarsal.,3. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,ANESTHESIA:, General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:, 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in the supine position. After general anesthesia was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in normal sterile technique. The left ankle tourniquet was then inflated. Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon. The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the periosteum of the first left metatarsal. All the tendinous neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft. Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact. The screws were sent to pathology for examination. The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification. The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding. The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy. Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished. The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft. Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent. The area was flushed copiously flushed with saline. The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material. All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time. The left ankle tourniquet was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels. The patient was given specific instructions and education on how to continue caring for his left foot surgery. The patient was also given pain medications, instructions on how to control his postoperative pain. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for his first postoperative appointment.
## 581 PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia. Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTIMATED BLOOD LOSS: ,Minimal.,COMPLICATIONS: ,There were no intraoperative complications.,DRAIN: ,None.,SPECIMENS: ,None.,HISTORY AND PHYSICAL: ,The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero. The patient has diagnosis of autism as well. The patient presented with bilateral knee flexion contractures, initially worse on right than left. He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play. The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed. Risks and benefits of the surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures. All questions were answered and mother and son agreed to above plan.,PROCEDURE NOTE: ,The patient was taken to operating room and placed supine on operating table. General anesthesia was administered. The patient received Ancef preoperatively. Nonsterile tourniquet was placed on the upper aspect of the patient's left thigh. The extremity was then prepped and draped in standard surgical fashion. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Esmarch was then removed. A small 3 cm incision was made over the distal medial hamstring. Hamstring tendons were isolated and released in order of semitendinosus, semimembranosus, and sartorius. The wound was then irrigated with normal saline and closed used 2-0 Vicryl and then 4-0 Monocryl. The wound was cleaned and dried and dressed with Steri-Strips. The area was infiltrated with total 10 mL of 0.25% Marcaine. The wound was then covered with Xeroform, 4 x 4s, and Bias. Tourniquet was released at 15 minutes. The patient was then placed in knee immobilizer. The patient tolerated the procedure well and subsequently taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The patient may weight bear as tolerated in his brace. He will start physical therapy in another week or two. The patient restricted from any PE for at least 6 week. He may return to school on 01/04/2008. He was given Vicodin for pain.
## 582 PROCEDURES:,1. Right and left heart catheterization.,2. Coronary angiography.,3. Left ventriculography.,PROCEDURE IN DETAIL:, After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory. Patient was prepped and draped in sterile fashion. Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire. Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire. The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter. The patient tolerated the procedure well and there were immediate complications were noted. Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY: The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery. No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches. No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY: The circumflex artery is a moderate sized vessel. The vessel is a stenotic lesion. After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22. The aortic pressure was 52/24. Right ventricular pressure was 58/14. RA pressure was 14. The aortic pressure was 127/73. Left ventricular pressure was 127/15. Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only. In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%. Severe mitral regurgitation was also noted.,IMPRESSION:,1. Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2. Severe mitral regurgitation.,3. No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,
## 583 PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux. The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration. He has failed outpatient antibiotic therapy and conservative methods. At this time, he desires to attempt surgical correction. The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone. He was counseled preoperatively about the strong probability of the hallux being a "floppy tail" after the surgery and accepts the fact. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively. The wound was on the planar medial, distal and dorsal medial. The wound's bases were fibrous. They did not break the bone at this point. They were each approximately 0.5 cm in diameter. After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied. Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block. Next, the foot was prepped and draped in the usual aseptic fashion. It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected. Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium. Next, the incision was deepened through the subcutaneous tissue. A heavy amount of bleeding was encountered. Therefore, a Penrose drain was applied at the tourniquet, which failed. Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis. Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery. Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon. The long extensor tendon was thickened and overall exhibited signs of hypertrophy. The transverse incision through the long extensor tendon was made with a #15 blade. Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint. Next, the extensor tendon was peeled dorsally and distally off the bone. Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx. This bone was removed with a sharp dissection. Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx. This was passed off as the infected bone specimen for microbiology and pathology. Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx. Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins. The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline. Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin. This bone was found to be hard and healthy appearing. The wound after irrigation was free of all debris and infected tissue. Therefore anaerobic and aerobic cultures were taken and sent to microbiology. Next, OsteoSet beads, tobramycin-impregnated, were placed. Six beads were placed in the wound. Next, the extensor tendon was re-approximated with #3-0 Vicryl. The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits. A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap. The patient tolerated the above anesthesia and procedure without complications. He was transported via a cart to the Postanesthesia Care Unit. His vitals signs were stable and vascular status was intact. He was given a medium postop shoe that was well-formed and fitting. He is to elevate his foot, but not apply ice. He is to follow up with Dr. X. He was given emergency contact numbers. He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home. The patient was discharged in stable condition.
## 584 PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:, Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia. The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET: ,There is no tourniquet time.,ESTIMATED BLOOD LOSS: ,Minimal.,COMPLICATIONS: ,No intraoperative complications.,HISTORY AND PHYSICAL: ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture. He underwent screw compression for the fracture in October 2007. The fracture has subsequently healed and the patient presents for hardware removal. The risks and benefits of surgery were discussed. The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion. All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. General anesthesia was then administered. The patient's left upper extremity was then prepped and draped in standard surgical fashion. Using his previous incision, dissection was carried down through the screw. A guide wire was placed inside the screw and the screw was removed without incident. The patient had an extension lag of about 15 to 20 degrees. Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex. The washer was also removed without incident. Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl. Wound was injected with 0.25% Marcaine. The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias. The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery. He is to follow up in one week's time for a wound check. This can be done at his primary care physician's office. The patient should keep his postop dressing for about 4 to 5 days. He may then wet the wound, but not scrub it. The patient may resume regular activities in about 2 weeks. The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.
## 585 PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:, The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 5-year, 5-month-old male who sustained a both-bone forearm fracture in September 2007. The fracture healed uneventfully, but then the patient subsequently suffered a refracture one month ago. The patient had shortening in arms, noted in both bones. The parents opted for surgical stabilization with nailing. This was performed one month ago on return visit. His ulnar nail was quite prominent underneath the skin. It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks.,Risks and benefits of the surgery were discussed with the mother. Risk of surgery incudes risks of anesthesia, infection, bleeding, changes in sensation in most of the extremity, need for longer casting. All questions were answered and mother agreed to above plan.,PROCEDURE IN DETAIL: ,The patient was seen in the operative room, placed supine on operating room table. General anesthesia was then administered. The patient was given Ancef preoperatively. The left elbow was prepped and draped in a standard surgical fashion. A small incision was made over the palm with K-wire. This was removed without incident. The wound was irrigated. The bursitis was curetted. Wounds closed using #4-0 Monocryl. The wound was clean and dry, dressed with Xeroform 4 x 4s and Webril. Please note the area infiltrated with 0.25% Marcaine. The patient was then placed in a long-arm cast. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: ,The patient will maintain the cast for 3 more weeks. Intraoperative nail was given to the mother. The patient to take Tylenol with Codeine as needed. All questions were answered.,
## 586 PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE: ,The patient was brought to the procedure room in satisfactory condition. The right groin was prepped and draped in routine fashion. An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively. Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter. Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1. LV is normal in size and shape with good contractility, EF of 60%.,2. LMCA normal.,3. LAD has 20% to 30% stenosis at the origin.,4. LCX is normal.,5. RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise. Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain. Follow up in the clinic.
## 587 PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest. It was accompanied by diaphoresis and shortness of breath. The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain. He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5. Stress images revealed left ventricular dilatations suggestive of multivessel disease. He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing. The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed. The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin. The needle was removed and a pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed and the sheath was flushed. A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis. The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter. The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views. This catheter was removed. The sheath was flushed the final time. The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:, This vessel is seen to be heavily calcified throughout its course. Begins as a moderate caliber vessel. There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, This vessel is heavily calcified in its proximal portion. It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex. There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches. There is sequential 80% and 90% stenosis in the mid-portion of the vessel. Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY: ,This vessel is also calcified in its proximal portion. There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery. There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system. There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1. Three-vessel coronary artery disease as described above.,2. Moderate mitral regurgitation per TEE.,3. Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4. Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.
## 588 PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:, General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation on her left lateral thigh below the greater trochanter, which was described by her parents as a birthmark. This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat, slightly hyperpigmented lesion. Although no isolated injury event can be recalled, the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh, and it has been treated with topical cautery in her primary care doctor's office, but with recurrence. She is here today for excision.,OPERATIVE FINDINGS: , The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation.,DESCRIPTION OF OPERATION: ,The patient came to the operating room, had an uneventful induction of general anesthesia. We conducted a surgical time-out, reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today. Preparation and draping was __________ ensued with a chlorhexidine based prep solution. The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1.2 cm. This entire area was infiltrated with 0.25% Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a #15 scalpel blade, excising the pyogenic granuloma, its base, and a small rim of surrounding normal skin. Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle-tip electrocautery pencil. The wound was closed in layers with a deep dermal roll of 5-0 Monocryl stitches supplemented by 5-0 intradermal Monocryl and Steri-Strips for final skin closure. The patient tolerated the procedure well. This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma. Blood loss was less than 5 mL and there were no complications.
## 589 PREOPERATIVE DIAGNOSIS:, Neurologic devastation secondary to nonaccidental trauma.,POSTOPERATIVE DIAGNOSES: , Neurologic devastation secondary to nonaccidental trauma.,PROCEDURE: , Laparoscopic G-tube placement (14-French 1.2-cm MIC-Key).,INDICATIONS FOR PROCEDURE: , This patient is a 5-month-old baby boy who presented unfortunately because of nonaccidental trauma. The patient suffered neurologic devastation. In order to facilitate enteral feedings, the plan is to place a G-tube as the patient cannot take by mouth. Consent was obtained by court order as the patient is a ward of the state.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's abdomen was prepped and draped in the usual sterile fashion. An incision was made through the umbilicus. Peritoneal cavity entered bluntly. A 5-mm trocar was introduced. Abdomen was insufflated with a 5-mm scope. No obvious pathology noted. We visualized the stomach. We chose the spot in the left upper quadrant for future G-tube site. I made a small incision on the skin there, put another 5-mm trocar at that site. Using a Babcock, we grasped the stomach along the greater curvature site for further G-tube. I pulled a knuckle of stomach through the incision and secured with 4-0 Vicryl. I then used 3-0 Prolene sutures as tacking sutures on either side of the future G-tube site taking full-thickness abdominal wall through stomach and back out the abdominal wall. I then pulled the knuckle of stomach back up through the incision, made a gastrotomy, and then put a 4-0 pursestring around the gastrotomy site, introduced the 14, 1.2- cm MIC-Key into the stomach. The gastrotomy site insufflated with 5 mL of saline. We then tied down the pursestring. On the laparoscopy, the G-tube looked to be in good position. I insufflated the stomach through the G-tube, which I did and removed air subsequently. I then placed 2 x 2 underneath the G-tube and tied down tacking sutures around the G-tube itself, placed the G-tube to gravity, desufflated the abdomen, closed the umbilical port site fascia with 3-0 Vicryl, closed skin with 5-0 Monocryl, and dressed with bacitracin, 2 x 2, and Steri-Strips. The patient was extubated in the operating room and taken back to recovery room. The patient tolerated the procedure well.
## 590 PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:, Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum. The preparation was excellent and all surfaces were well seen. The hypopharynx appeared normal. The esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted. The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors. Above the GE junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm. This appears to be consistent with Barrett esophagus. Multiple biopsies were taken from numerous areas in this region. There was no active ulceration or inflammation and no stricture. The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus. The gastric body had normal mucosa throughout. Numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance. Biopsies were taken from the antrum to rule out Helicobacter pylori. A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions. The scope was passed through the pylorus, which was patent and normal. The mucosa throughout the duodenum in the first, second, and third portions was entirely normal. The scope was withdrawn and the patient was sent to the recovery room. He tolerated the procedure well.,FINAL DIAGNOSES:,1. A short-segment Barrett esophagus.,2. Hiatal hernia.,3. Incidental fundic gland polyps in the gastric body.,4. Otherwise, normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:,1. Follow up biopsy report.,2. Continue PPI therapy.,3. Follow up with Dr. X as needed.,4. Surveillance endoscopy for Barrett in 3 years (if pathology confirms this diagnosis).
## 591 PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT: ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection. The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment. The patient now has exposed bone and osteomyelitis in the second toe. The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position. A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia. After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit. The foot and ankle were then prepped in the normal sterile orthopedic manner. The foot was elevated and an Esmarch bandage applied to exsanguinate the foot. The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table. Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site. Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit. Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint. Care was taken to identify bleeders and cautery was used as necessary for hemostasis. After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint. The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination. Attention was then directed to closure of the wound. All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident. Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges. Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety. Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin. Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin. This was obtained using #2-0 nylon suture. Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze. The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression. The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved. The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated. The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure. Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot. The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour. The patient was instructed to continue her regular medications. The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30. The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present. The second digit was sent to Pathology for gross and micro.
## 592 PREOPERATIVE DIAGNOSES: , Dysphagia and esophageal spasm.,POSTOPERATIVE DIAGNOSES: , Esophagitis and esophageal stricture.,PROCEDURE:, Gastroscopy.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum. The hypopharynx was normal and the upper esophageal sphincter was unremarkable. The esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors. At this point, there were several linear erosions and a sense of stricturing at 38 cm. Below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors. The mucosa within the hernia was normal. The gastric lumen was normal with normal mucosa throughout. The pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion. During withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia. It was decided to attempt dilation of the strictured area, so an 18-mm TTS balloon was placed across the stricture and inflated to the recommended diameter. When the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one. No stretching of the mucosa took place. The balloon was deflated and the scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Esophagitis.,2. Minor stricture at the gastroesophageal junction.,3. Hiatal hernia.,4. Otherwise normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS: ,Continue proton pump inhibitor therapy.
## 593 PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,
## 594 OPERATION PERFORMED:, Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1. Severe dental caries.,2. Non-restorable teeth.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY: ,The patient was first seen by me on 04/26/2007. She had a history of open heart surgery at 11 months' of age. She presented with severe anterior caries with most likely dental extractions needed. Due to her young age, I felt that she would be best served in the safety of the hospital operating room. After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION: ,This child was brought to Hospital Day Surgery and is accompanied by her mother. There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment. After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment. The patient's history and physical examination was reviewed. Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with a nasal endotracheal tube and the tube was stabilized. The head was wrapped and the eyes were taped shut for protection. An angiocatheter was placed in the left hand and an IV was started. The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath. A moist continuous throat pack was placed beyond the tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative clinical photographs were taken. Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography. After the radiographs were taken, the lead shield was removed. Prophylaxis was then performed using prophy cup and fluoridated prophy paste. The teeth were then rinsed well and the patient's oral cavity was suctioned clean. Clinical and radiographic examinations followed and areas of decay were noted. During the restorative phase, these areas of decay were entered into and removed. Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. Final caries was removed and was confirmed upon reaching hard, firm sounding dentin. Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were then taken. The continuous gauze throat pack was removed with continuous suction with visualization. Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS: ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene. All primary teeth were present. Dental caries were present on the following teeth: Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries. The remainder of her teeth and soft tissues were within normal limits. The following restorations and procedures were performed: Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION: ,The mother was informed of the completion of the procedure. She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. They will contact to my office in the event of immediate postoperative complications. After full recovery, she was discharged from the recovery room in the care of her mother.
## 595 PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table. A tourniquet applied to the upper arm. The extremity was prepped in a usual manner for a surgical procedure and draped off. The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted. The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine. A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room. The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint. The tourniquet was released. Circulation returned to the fingers. The patient then was allowed to awaken and left the operating room in good condition.
## 596 OPERATION PERFORMED:, Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,POSTOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,3. Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: ,1 hour and 22 minutes.,BRIEF HISTORY: ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort. Mom reported history of high fever after surgery and he has one seizure previously. He has history of trauma to his front teeth and physician put him on antibiotics. He was only cooperative for having me do a visual examination on his anterior teeth. Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted. Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION: ,The child was brought to the Hospital Day Surgery accompanied by his mother. There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment. After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment. The patient's history and physical examination was reviewed. He was given factor for appropriately for his hemophilia prior to being taken back to the operating room. Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with an oral tube and the tube was stabilized. The head was wrapped and IV was started. The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath. A moist continuous throat pack was placed beyond tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative clinical photographs were taken. Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph. After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste. The patient's teeth were rinsed well. The patient's oral cavity was suctioned clean. Clinical and radiographic examination followed and areas of decay were noted. During the restorative phase, these areas of decay were incidentally removed. Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________ bonded with a one-step bonding agent. Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. Non-restorable primary teeth would be extracted. The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies. Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were then taken. The continuous gauze throat pack was removed with continuous suction with visualization. Topical fluoride was then placed on the teeth. At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene. All primary teeth were present. Dental carries were present on the following teeth: Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries. The remainder of his teeth and soft tissues were within normal limits. The following restoration and procedures were performed. Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite. Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam. Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION: ,The mother was informed of the completion of the procedure. She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother. She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,
## 597 PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal postoperative hernia repair.,2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3. Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1. Continue proton pump inhibitors.,2. Use Reglan 10 mg three to four times a day.
## 598 PROCEDURE:, Gastroscopy.,PREOPERATIVE DIAGNOSIS:, Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop. The preparation was good and all surfaces were well seen. The hypopharynx was normal with no evidence of inflammation. The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate. The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's. Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food. The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration. Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation. The scope was withdrawn and the patient was sent to recovery room. She tolerated the procedure well.,FINAL DIAGNOSES:,1. Normal post-gastric bypass anatomy.,2. No evidence of inflammation or narrowing to explain her symptoms.
## 599 PREOPERATIVE DIAGNOSIS: , Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATION: , Cystoscopy and removal of foreign objects from the urethra.,BRACHYTHERAPY:, Iodine 125.,ANESTHESIA: , General endotracheal. The patient was given Levaquin 500 mg IV preoperatively.,Total seeds were 59. Activity of 0.439, 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold, 4 needles. Please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back.,BRIEF HISTORY: , This is a 72-year-old male who presented to us with elevated PSA and prostate biopsy with Gleason 6 cancer on the right apex. Options such as watchful waiting, brachytherapy, radical prostatectomy, cryotherapy, and external beam radiation were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, erectile dysfunction, urethral stricture, dysuria, burning pain, hematuria, future procedures, and failure of the procedure were all discussed. The patient understood all the risks, benefits, and options and wanted to proceed with the procedure. The patient wanted to wait until he came back from his summer vacations, so a one dose of Zoladex was given. Prostate size measured about 15 g in the OR and about 22 g about two months ago. Consent was obtained.,DETAILS OF THE OPERATION: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient had a Foley catheter placed sterilely. The scrotum was taped up using Ioban. Transrectal ultrasound was done. The prostate was measured 15 g. Multiple images were taken. A volume study was done. This was given to the physicist, Dr. X was present who is radiation oncologist who helped with implanting of the seeds. Total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles. Total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside. They were done directly under transrectal ultrasound vision. The seeds were placed directly under ultrasound guidance. There was a nice distribution of the seeds. A couple of more seeds were placed on the right side due to the location of the prostate cancer. Subsequently at the end of the procedure, fluoroscopy was done. Couple of images were obtained. Cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra, which was grasped and pulled out using grasper, which was difficult to get the seed off of the spacers, which was actually pulled out. There were no further seeds visualized in the bladder. The bladder appeared normal. At the end of the procedure, a Foley catheter was kept in place of 18 French and the patient was brought to recovery in stable condition.
## 600 PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED: ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: , Povidone.,INDICATION:, This is an 83-year-old male with herniation syndrome with large subdural hematoma 100%. This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room intubated. The patient previously was given fresh frozen plasma plus recombinant activated factor VII. The patient had a roll placed on his right shoulder, head was maintained three point fixation with a Mayfield headholder. The right side of the head was shaved, thoroughly prepped and draped, a large ? scalp incision was marked, infiltrated with local and incised with a scalpel, Raney clips were applied to the scalp margins, hemostasis, temporalis muscle and fascia, pericranium opened and aligned with incision, flap was reflected anteriorly. Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator, then using Midas Rex drill with a B1 foot plate a free flap was turned. The dura was opened in a cruciate fashion, acute subdural hematoma was evacuated. There was a small arterial bleeder in the anterior parietal region, which was controlled with bipolar electrocautery. Using suction and biopsy forceps, acute clot was resected from the frontotemporoparietal and occipital poles, subdural space was irrigated, no further bleeders were encountered. Dura was closed with 4-0 Nurolon. A subdural Camino ICP catheter was placed in the subdural space. Bone flaps secured in place with neuro clips with 5 mm screws, central pack up suture was placed, dural tack up sutures were placed using 4-0 Nurolon prior to placement of the bone flap. The wound was irrigated with saline, temporalis muscle and fascia closed with 2-0 Vicryl, subgaleal Hemovac was placed, galea was closed with 2-0 Vicryl, and scalp with staples. ICP monitor and the Hemovac were sutured in place with 2-0 Vicryl. The patient was taken out of the head holder, a sterile dressing placed. The head was wrapped. The patient was taken directly to ICU, still intubated in guarded condition. Brain was nicely soft and pulsatile. At the termination of the procedure, no significant contusion of the brain was identified. Final sponge and needle counts are correct. Estimated blood loss 400 cc.
## 601 S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.,A - ,1. Painful feet.,
## 602 PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear "S"-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition.
## 603 PREOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,PROCEDURE PERFORMED:,1. Irrigation debridement.,2. Removal of foreign body of right foot.,ANESTHESIA:, Spinal with sedation.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus. The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot. He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room. He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics. It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity. After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff. The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position. All bony prominences were well padded at this time. The Department of Anesthesia was administered spinal anesthetic to the patient. Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion. Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from. At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads. Upon incising this, there was a foul smelling purulent fluid, which flowed from this region. Aerobic and anaerobic cultures were taken as well as gram stain. The area was explored and it ________ to the dorsum of the foot. There was no obvious joint involvement. After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound. The wound was again inspected with no more gross purulent or necrotic appearing tissue. The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage. At this time, the Department of Anesthesia reversed the sedation. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications.,DISPOSITION: ,The patient will be followed on a daily basis for possible repeat irrigation debridement.
## 604 PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:, Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion. After 2% lidocaine was instilled, the anterior urethra is normal. The prostatic urethra reveals mild lateral lobe obstruction. There are no bladder tumors noted.,IMPRESSION:, The patient has some mild benign prostatic hyperplasia. At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed.
## 605 PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1. Severe tracheobronchitis.,2. Mild venous engorgement with question varicosities associated pulmonary hypertension.,3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a. Right lower lobe bronchoalveolar lavage.,b. Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite. The patient had previously been on Coumadin and then heparin. Heparin was discontinued approximately one-and-a-half hours prior to the procedure. The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx. Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure. Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure. The patient was premedicated with 50 mg of Demerol and 2 mg of Versed. After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx. There was minimal redundant oral soft tissue in the oropharynx. There was mild erythema. Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied. Vocal cord motion was normal. The bronchoscope was then advanced through the larynx into the trachea. There was evidence of moderate inflammation with prominent vascular markings and edema. No frank blood was visualized. The area was suction clear of copious amounts of clear white secretions. Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem. The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe. There was significant amount of inflammation, induration, and vascular tortuosity in these regions. No frank blood was identified. No masses or lesions were identified. There was senile bronchiectasis with slight narrowing and collapse during the exhalation. The air was suctioned clear. The bronchoscope was withdrawn and advanced into the right main stem. Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized. Again significant amounts of tracheobronchitis was noted with vascular infiltration. In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this. The bronchoscope was removed and advanced into the right middle and right lower lobe. There was marked injection and inflammation in these regions. In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region. Again, white clear secretions were identified. No masses or other processes were noted. The area was suctioned clear. A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe. The bronchoscope was then withdrawn and readvanced into the right upper lobe. Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained. Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine. The area remained clear. No further hemorrhage was identified. The bronchoscope was subsequently withdrawn. The patient tolerated the procedure well and was stable throughout the procedure. No further hemoptysis was identified. The patient was sent to Recovery in good condition.
## 606 PREPROCEDURE DIAGNOSIS:, Foreign body of the right thigh.,POSTOPERATIVE DIAGNOSIS: , Foreign body of the right thigh, sewing needle.,PROCEDURE: ,Removal of foreign body of right thigh.,HISTORY: ,This is a 71-year-old lady who has been referred because there is a mass in the right thigh. The patient comes with an ultrasound and apparently was diagnosed with a blood clot. On physical examination, blood pressure was 152/76 and temperature was 95.0. The patient is 5 feet 1 inch and weighs 170. On examination of her right thigh, there is a transverse area of ecchymosis in the upper third of the thigh. There is a palpation of a very sharp object just under the skin. The patient desires for this to be removed.,DESCRIPTION OF PROCEDURE: , After obtaining informed consent in our office, the area was prepped and draped in usual fashion. Xylocaine 1% was infiltrated in the end of the object that was the sharpest and a small incision was made there and then I pushed the foreign body through partially and then grabbed it with a hemostat and took it out and it was a 1-1/2-inch sewing needle.,Compression was applied for a few minutes and then a Band-Aid was applied.,The patient was given a tetanus toxoid 0.5 cc IM shot injection and then she was dismissed with instructions of return if inflammatory signs develop.
## 607 PREOPERATIVE DIAGNOSIS:, Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:, Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,PROCEDURES PERFORMED: ,1. Repair flexor carpi radialis.,2. Repair palmaris longus.,ANESTHETIC: , General.,TOURNIQUET TIME: ,Less than 30 minutes.,CLINICAL NOTE: ,The patient is a 21-year-old who sustained a clean laceration off a teapot last night. She had lacerated her flexor carpi radialis completely and 90% of her palmaris longus. Both were repaired proximal to the carpal tunnel. The postoperative plans are for a dorsal splint and early range of motion passive and active assist. The wrist will be at approximately 30 degrees of flexion. The MPJ is at 30 degrees of flexion, the IP straight. Splinting will be used until the 4-week postoperative point.,PROCEDURE: , Under satisfactory general anesthesia, the right upper extremity was prepped and draped in the usual fashion. There were 2 transverse lacerations. Through the first laceration, the flexor carpi radialis was completely severed. The proximal end was found with a tendon retriever. The distal end was just beneath the subcutaneous tissue.,A primary core stitch was used with a Kessler stitch. This was with 4-0 FiberWire. A second core stitch was placed, again using 4-0 FiberWire. The repair was oversewn with locking, running, 6-0 Prolene stitch. Through the second incision, the palmaris longus was seen to be approximately 90% severed. It was an oblique laceration. It was repaired with a 4-0 FiberWire core stitch and with a Kessler-type stitch. A secure repair was obtained. She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair. The fascia was released proximally and distally to give her more room for excursion of the repair.,The tourniquet was dropped, bleeders were cauterized. Closure was routine with interrupted 5-0 nylon. A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted. The splint was dorsal. The patient was sent to the recovery room in good condition.
## 608 PREOPERATIVE DIAGNOSIS: ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1. Foreign body, left vallecula at the base of the tongue.,2. Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:, ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year-old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation. The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken. The patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success. The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body. Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,PROCEDURE: , After verbal informed consent was obtained, the patient was placed in the upright position. The fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris. There was visualized some bilateral caudal spurring of the septum. The turbinates were within normal limits. There was some posterior nasoseptal deviation to the left. The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity. The nasal mucous membranes were pink and moist. There was no evidence of mass, ulceration, lesion, or obstruction.,The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally. There was evidence of some mild erythema in the right fossa Rosenmüller. There was no evidence of mass lesion or ulceration in this area, however. The eustachian tubes were patent without obstruction. The scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized. There was evidence of a 1.5 cm left vallecular white foreign body. The rest of the oropharynx was without abnormality. The epiglottis was within normal limits and was noted to be omega in shape. There was no edema or erythema to the epiglottis. The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords. There was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords. The laryngeal surface of the epiglottis was within normal limits. There was no evidence of mass lesion or nodularity of the vocal cords. The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion. The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam. The glottic aperture was completely patent with inspiration. The anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits. The scope was then removed without difficulty. The patient tolerated the procedure well and remained in stable condition.,FINDINGS:,1. A 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region. There is no evidence of supraglottic or piriform sinuses foreign body.,2. Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller. No mass is appreciated at this time.,PLAN:, The patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m. Airway precautions were instituted. The patient currently remained in stable condition.
## 609 PREOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM. He was referred for stereotactic radiosurgery. The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits. The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment. He was placed on the treatment table. The Aquaplast mask was constructed. Initial imaging was obtained by the CyberKnife system. The patient was then transported over to the CT scanner at Stanford. Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered. Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices. These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me. I outlined the tumor volume. Inverse treatment planning was used to generate the treatment plan for this patient. This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator. The maximum dose within this center of treatment volume was 23.81 Gy. The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm. The volume treated at the reference dose was 98%. The coverage isodose line was 79%. The conformality index was 1.74 and modified conformality index was 1.55. The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite. He was placed on the treatment table. The Aquaplast mask was applied. Initial imaging was used to bring the patient into optimal position. The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin. He tolerated the procedure well. He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months. The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.
## 610 PREOPERATIVE DIAGNOSES:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1. Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2. Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:, General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure. He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level. There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position. General anesthetic was administered. Left arm was prepped and draped in appropriate manner. A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue. Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop. Transverse graftotomy was created. A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow. A fistulogram was performed and the above findings were noted. In a retrograde fashion, the proximal anastomosis was patent. There was no narrowing within the forearm graft. Both veins were flushed with heparinized saline and controlled with a vascular clamp. A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia. Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated. The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself. The vein was controlled with vascular clamps. Longitudinal venotomy created along the anteromedial wall. A 7 mm graft was brought on to the field and this was cut to shape and size. This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures. Good backflow bleeding was confirmed. The vein flushed with heparinized saline and graft was controlled with vascular clamp. The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture. Good backflow bleeding was confirmed. The graftotomy was then closed with interrupted #6-0 Prolene suture. Flow through the fistula was permitted, a good flow passed. The wound was copiously irrigated with antibiotic solution. Sponge, needles, instrument counts were correct. All surgical sites were inspected. Good hemostasis was noted. The incision was closed in layers with absorbable sutures. Sterile dressing was applied. The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.
## 611 POSTOPERATIVE DIAGNOSIS:, Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:, Flexible fiberoptic bronchoscopy diagnostic with:,a. Right middle lobe bronchoalveolar lavage.,b. Right upper lobe bronchoalveolar lavage.,c. Right lower lobe transbronchial biopsies.,COMPLICATIONS:, None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION: ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:, After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions. The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure. 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved. Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx. Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg. With this, adequate consciousness sedation was achieved. 3 cc of 4% viscous Xylocaine was applied to the right nares. The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions. Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc. The bronchoscope was then advanced through the larynx into the trachea. The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions. These were suctioned clear. The bronchoscope was then advanced through the carina, which was sharp. Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized. There was mild tracheobronchitis with mild friability throughout. There was modest amounts of white secretion. There were no other findings including evidence of mass, anatomic distortions, or hemorrhage. The bronchoscope was subsequently withdrawn and advanced into the right mainstem. Again, each segment and subsegment was well visualized. The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments. No specific masses or other lesions were identified throughout the tracheobronchial tree on the right. There was mild tracheal bronchitis with friability. Upon coughing, there was punctate hemorrhage. The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe. These again had no other anatomic lesions identified. The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained. The bronchoscope was withdrawn and the area was suctioned clear. The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed. Samples were taken and the bronchoscope was removed suctioned the area clear. The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe. Minimal hemorrhage was identified and suctioned clear without difficulty. The bronchoscope was then withdrawn to the mainstem. The area was suctioned clear. Fluoroscopy revealed no evidence of pneumothorax. The bronchoscope was then withdrawn. The patient tolerated the procedure well without evidence of desaturation or complications.
## 612 PREOPERATIVE DIAGNOSIS:, Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:, Atrophic vaginitis.,PROCEDURE: ,The patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position. The patient then had flexible scope placed through the urethral meatus and into the bladder. Bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body. Significant atrophic vaginitis is noted.,IMPRESSION: , Atrophic vaginitis with overactive bladder with urge incontinence.,PLAN: , The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks.
## 613 PREOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1. Left breast flap revision.,2. Right breast flap revision.,3. Right breast reduction mammoplasty.,4. Right nipple reconstruction.,5. Left abdominal scar deformity.,6. Right abdominal scar deformity.,7. Excision of right breast medial lesion enclosure.,8. Excision of right breast lateral lesion enclosure.,ANESTHESIA:, General.,COMPLICATIONS:, None.,DRAINS:, None.,SPECIMENS:, Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction. The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated. The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:, The patient was brought to the operating room, placed supine on the operative table. After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant. The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants. Once this was performed, the vertical reduction mammoplasty was outlined. Prior to that, the nipple reconstruction was performed with a keyhole pattern flap. The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie. The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures. Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures. Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions. Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb. Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex. Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology. They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required. Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect. There was a larger excision required measuring approximately 15 x 3 cm. The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition. All instruments, needle counts, and sponges were correct at the end of the case.
## 614 PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. Withdrawal notes an otherwise normal descending, rectosigmoid and rectum. Retroflexion noted no abnormality of the internal ring. No hemorrhoids were noted. Withdrawal from the patient terminated the procedure.
## 615 PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.
## 616 INDICATION: , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE: ,
## 617 PREOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,4. Changes consistent with acute and chronic bronchitis.,5. Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6. Left vocal cord irregularity.,PROCEDURE PERFORMED: ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring. Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air. Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication. As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx. The cords were noted to oppose bilaterally on phonation. There was some slight mucosal irregularity noted on the vocal cord on the left side. Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature. The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled. At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled. Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion. The mucosa was diffusely friable throughout. Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled. At this point, the bronchoscope was then advanced to the right bronchus intermedius. At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening. The mucosal area throughout this region was severely friable. Additional lidocaine was instilled as well as topical epinephrine. At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed. At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible. So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized. At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty. At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius. At this time, multiple mucosal biopsies were performed with some mild oozing noted. Several aliquots of normal saline lavage followed. After completion of multiple biopsies there was good hemostasis. Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed. Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments. The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem. Additional lidocaine was instilled. The bronchoscope was advanced to the left upper and lower lobe subsegments. There was no endobronchial lesion visualized. There is mild diffuse erythema and fibromucosa was noted throughout. No endobronchial lesion was visualized in the left bronchial system. The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system. At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared. There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout. The bronchoscope was subsequently withdrawn and the patient was sent to recovery room. During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%. The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea. This was confirmed by her daughter and mother who were also present at the bedside postprocedure. The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well. The patient also admitted to continued smoking in spite of all of the above. The patient was extensively counseled regarding the continued smoking especially with her present symptoms. She was advised regarding smoking cessation. The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off. The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room. There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted. The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis. At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission. However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.
## 618 PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1. Left arm fistulogram.,2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3. Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:, Sedation with local.,COMPLICATIONS:, None.,CONDITION:, Fair.,DISPOSITION:, PACU.,ACCESS SITE:, Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed. The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound. The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate. A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis. The patient presents today for a left arm fistulogram with angioplasty. The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS: ,The patient was brought to the angio suite and laid supine on the table. After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion. Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure. The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound. The cephalic vein in the proximal upper arm region appeared to be of adequate caliber. There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis. The cephalic vein in the proximal forearm region was easily compressible. The skin overlying the vessel was injected with 1% lidocaine solution. A small incision was made with the #11 blade. The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath. The sheath was advanced over the wire. A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis. The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire. The sheath was aspirated and flushed with heparinized saline solution. A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery. A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery. After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table. This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated. The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement. However, there is still a remainder of residual stenosis. The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed. The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis. The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery. A 4 x 20 mm cutting balloon was obtained and prepped on the back table. The 5 French sheath was then exchanged for a 6 French sheath. The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg. The balloon was then deflated and removed over the wire. A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg. A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis. The patient actually had a nice palpable thrill at this point. The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis. The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound. The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution. A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein. A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence. The 5 French introducer sheath was then exchanged for a 5 French sheath. The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis. The balloon was inflated to 14 mmHg. The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results. The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes. After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied. The patient tolerated the procedure without any complications. I was present for the entire case. The sponge, instrument, and needle counts are correct at the end of the case. The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:, The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein. After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis. Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein. Postangioplasty demonstrated excellent results with the standard balloon. There was no evidence of any contrast extravasation.,IMPRESSION,1. High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally. Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2. A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein. Poststandard balloon angioplasty demonstrated excellent results. No evidence of contrast extravasation.
## 619 PREOPERATIVE DIAGNOSES:,1. Dysphagia.,2. Right parapharyngeal hemorrhagic lesion.,POSTOPERATIVE DIAGNOSES:,1. Dysphagia with no signs of piriform sinus pooling or aspiration.,2. No parapharyngeal hemorrhagic lesion noted.,3. Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,PROCEDURE PERFORMED: ,Fiberoptic nasolaryngoscopy.,ANESTHESIA: , None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 93-year-old Caucasian male who was admitted to ABCD General Hospital on 08/07/2003 secondary to ischemic ulcer on the right foot. ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation. The patient subsequently resolved with his dysphagia and workup of Speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway. This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,PROCEDURE DETAILS: ,The patient was brought in the semi-Fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx. The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx. The patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx. There were no signs of any obstruction. The epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions. The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions. The scope was then pulled out and the patient tolerated the procedure well. At this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.
## 620 PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:, Rectal bleeding.,POSTOPERATIVE DIAGNOSIS: ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon. At this point, stool occupied the lumen, preventing further passage. The colon distal to this was well cleaned out and easily visualized. The mucosa was normal throughout the regions examined. Numerous diverticula were seen. There was no blood or old blood or active bleeding. A retroflexed view of the anorectal junction showed no hemorrhoids. He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Sigmoid and left colon diverticulosis.,2. Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3. The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1. Follow up with Dr. X as needed.,2. If there is further bleeding, a full colonoscopy is recommended.
## 621 MEDICATIONS:, None.,DESCRIPTION OF THE PROCEDURE:, After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn. The mucosa appeared normal. Retroflex examination of the rectum was normal.
## 622 PREOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,6. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE: ,ICU. Room #164.,ANESTHESIA/SEDATION:, Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,: The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance. The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation. Chest x-ray as noted above revealed complete atelectasis of the left lung. The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,: A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots. These were lavaged with several aliquots of normal saline until cleared. The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope. The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina. The endotracheal tube was noted to be in good position. The bronchoscope was advanced through the distal trachea. There was a white tissue completely obstructing the left main stem at the carina. The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned. Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen. The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes. There was diffuse mucus impactions/tissue as well as intermittent clots. There was no evidence of any active bleeding noted. Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted. Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system. There is no plugging or obstruction of the right bronchial system. The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina. The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure. Throughout the procedure, pulse oximetry was greater than 95% throughout. There is no hemodynamic instability or variability noted during the procedure. Postprocedure chest x-ray is pending at this time.
## 623 PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Bilateral facet Arthrogram at L34, L45, L5S1.,2. Bilateral facet injections at L34, L45, L5S1.,3. Interpretation of radiograph.,ANESTHESIA: ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view. A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left. Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side. This was performed using the oblique view under fluoroscopy to the enable the view of the "Scotty Dog," After obtaining the "Scotty Dog" view the joints were easily seen. Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow. After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected. Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint. The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint. The 22-gauge needle was then removed. Pressure was place over the puncture site for approximately one minute. This exact same procedure was then repeated along the left-sided facets at L45, and L5S1. This exact same procedure was then repeated on the right side. At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1. Visualizing the "Scotty Dog" technique under fluoroscopy facilitated this. Dye spread into each joint space is visualized. No venous or arterial run-off is noted. No epidural run-off is noted. The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.
## 624 PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:, Incompetent glottis.,OPERATION PERFORMED:,1. Fat harvesting from the upper thigh.,2. Micro-laryngoscopy.,3. Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion. A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space. After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin. After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device. Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition. Estimated blood loss was negligible.
## 625 PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD. Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1. Right common femoral artery cannulation.,2. Conscious sedation using IV Versed and IV fentanyl.,3. Retrograde bilateral coronary angiography.,4. Abdominal aortogram with pelvic runoff.,5. Left external iliac angiogram with runoff to the patient's left foot.,6. Left external iliac angiogram with runoff to the patient's right leg.,7. Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:, The patient was taken to the cardiac catheterization laboratory after having a valid consent. He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery. The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta. The wire was removed, the catheter was flushed. The catheter was engaged in the left main. Injections were performed at the left main in different views. The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire. The wire was removed, the catheter was flushed. The catheter was engaged in the RCA. Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire. The wire was removed. The catheter was flushed. Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation. Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA. The Omniflush was then removed. Through the wire, a Royal Flush catheter was then advanced into the left external iliac. The wire was removed. Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed. The catheter was then retracted into the left common iliac. Angiograms were performed of the left common iliac with runoff to the patient's left groin. The catheter was then positioned at the level of the right common iliac. Angiogram of the right common iliac with runoff to the patient's right leg was then performed. The catheter was then removed with the help of a J-wire. The J-wire was left in the abdominal aorta. Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed. The arterial sheath was then removed after being flushed. Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications. At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:, Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion. No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel. The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion. These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:, Right renal artery with luminal irregularities. Left renal artery with luminal irregularities. The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion. Left external iliac with 25% to 40% lesion. Left common femoral with 25% to 40% lesion. Left SFA with 25% lesion. Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions: Severe coronary artery disease. Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD. We will proceed with revascularization of the right external iliac as well as right common femoral. Discontinue tobacco.
## 626 PREOPERATIVE DIAGNOSIS:, Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1. Bilateral upper lobe cavitary lung masses.,2. Final pending pathology.,3. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite. After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis. Topical lidocaine was utilized for anesthesia. Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent. This may be normal anatomic variant. The scope was advanced into the trachea. The main carina was sharp in appearance. Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized. Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left. No specific intrinsic masses were noted. Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe. Also cytologic brushings and protected bacteriologic brushing specimens were obtained. Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe. During lavage, some caseous appearing debris appeared intermittently. The specimens were collected and sent to the lab. Procedure was terminated with hemostasis having been verified. The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.
## 627 PREOPERATIVE DIAGNOSIS:,1. Hemoptysis.,2. History of lung cancer.,POSTOPERATIVE DIAGNOSIS:, Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:, Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:, General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain. Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis. She was brought to endoscopy suite #4 and informed consent was obtained. ,PROCEDURE DETAILS: ,The patient was placed in the supine position and intubated by the Anesthesia Service. Intravenous sedation was given as per Anesthesia. The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea. The right mainstem bronchus was examined. The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted. Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot. Tumor completely occluded both segments of the right middle lobe. Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions. Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus. Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions. The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions. There were some secretions noted throughout the left lung. The scope was retracted and passed again to the right mainstem bronchus. The area of the right middle lobe was reexamined. The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation. It did not appear as if a scope or cannula could be passed distal to the tumor. Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained. The area was examined for approximately one minute for assurance of adequate hemostasis. The scope was then retracted and the patient was sent to the recovery room in stable condition. She will be extubated as per the Anesthesia Service. Cytology and cultures were not sent due to the patient's known diagnosis. Further recommendations are pending at this time.
## 628 PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:, A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained. The patient was noted to have irregular contractions. She was given 1 dose of subcutaneous terbutaline which resolved her contraction. A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation. There was noted to be adequate fluid. Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained. Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring. Following successful external cephalic version, the patient was placed on continuous external fetal monitoring. She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version. She did not have regular contractions and therefore she was felt to be stable for discharge to home. She was given appropriate labor instructions.
## 629 PREOPERATIVE DIAGNOSIS:, Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:, Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS: ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:, Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:, One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE: ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing. Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17. Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was transported to operating room #4 at Clinic. He was laid supine on the operating room table. ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion. Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision. After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed. This was sent for aerobic and anaerobic micro. Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed. The left masticator space was thoroughly explored as well as the left submandibular space and submental space. Pus was drained from this site. Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack. Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block. Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17. The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed. This pus was evacuated intraorally __________ suction. The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture. A tack stitch intraorally with 3-0 chromic suture was placed. The throat pack was then removed. An orogastric tube was placed and removed all other stomach contents and then removed. At this point, the procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transported to PACU in good condition.
## 630 PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3. No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1. Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2. Total laminectomy C3, C4, C5, and C6.,3. Excision of scar tissue.,4. Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:, 1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:, Less than 250 cc.,INDICATIONS FOR THE OPERATION: ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression. Last surgery consisted of four-level decompression on 08/28/06. The patient continued to complain of posterior neck pain radiating to both trapezius. Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis. It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial. Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation. Operation and expected outcome risks and benefits were discussed with him prior to the surgery. Risks include but not exclusive of bleeding and infection. Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection. There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord. This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma. There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis. This too may require return to the operating room for evacuation of said pseudomeningocele and repair. The patient understood the risk of the surgery. I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring. The SSEPs were normal, and the EMGs were silent during the entire case. After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support. Shave was then carried out over the occipital and suboccipital region. All pressure points were padded. I proceeded to mark the hypertrophic scar for excision. This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10. Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar. Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified. There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina. With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery. There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel. By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7. There was significant epidural bleeding, which was carefully coagulated. At two points, I had to pack this with small pieces of Gelfoam. After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage. Area was irrigated with saline and bacitracin and then lined with Tisseel. The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch. The patient was extubated and transferred to recovery.
## 631 PREOPERATIVE DIAGNOSIS:, Left supraorbital deep complex facial laceration measuring 6x2 cm.,POSTOPERATIVE DIAGNOSIS: , Left supraorbital deep complex facial laceration measuring 6x2 cm.,PROCEDURE PERFORMED: , Plastic closure of deep complex facial laceration measuring 6x2 cm.,ANESTHESIA: , Local anesthesia with 1% lidocaine with 1:100,000 epinephrine, total of 2 cc were used.,SPECIMENS: , None.,FINDINGS: , Deep complex left forehead laceration.,HISTORY: , The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead. The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site. He was brought to the Emergency Room, where a CAT scan of the head and facial bumps was performed, which were negative.,Prior to performing surgery informed consent was obtained from the patient who was well aware of the risks, benefits, alternatives and complications of the surgery to include infection, bleeding, cosmetic deformity, significant scarring, need for possible scar revision. The patient was allowed to ask all questions he wanted, and they were answered in a language he could understand. He wished to pursue surgery and signed the informed consent.,PROCEDURE: , The patient was placed in the supine position. The wound was copiously irrigated with normal saline on irrigating tip. After one liter of irrigation, the wound was prepped and draped in the usual sterile fashion. The incision was then localized with a solution of 1% lidocaine with 1:100,000 epinephrine, a total of less than 2 cc was used. We then reapproximated the wound in double-layered fashion with deep sutures of #5-0 Vicryl, two interrupted sutures were used, and then the skin was closed with interrupted sutures of #5-0 nylon. The wound came together very nicely. Tincture of Benzoin was placed. Steri-Strips were placed over the top and a small amount of bacitracin was placed over the Steri-Strips. The patient tolerated the procedure well with no complications.
## 632 PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS: ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:, Local with sedation.,INDICATION:, The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion. He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids. The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes. This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid. The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact. Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate. The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma. Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid. The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures. An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.
## 633 PREOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,PROCEDURES,1. Exploratory laparotomy.,2. Extensive lysis of adhesions.,3. Right salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS: ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them. The large and small bowels were completely enveloping a large right ovarian cystic mass. Normal anatomy was difficult to see due to adhesions. Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid. Cyst wall, tube, and ovary were stripped away from the bowel. Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube. There was excellent postoperative hemostasis.,PROCEDURE: ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty. She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion. A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision. Incision was carried down carefully until the peritoneal cavity was reached. Care was taken upon entry of the peritoneum to avoid injury of underlying structures. At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery. The omentum was carefully stripped away from the patient's right side developing a window. This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum. A large mass of bowel was noted to be adherent to itself causing a quite tortuous course. Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis. Excellent hemostasis was noted. The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst. Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst. Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured. Large amount of turbid fluid was noted and was evacuated. The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel. Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter. This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl. A suture ligature of #0 Vicryl was used to obtain hemostasis. Excellent hemostasis was noted at this pedicle. The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum. Care was taken at the side of the remnant of the uterine vessels. However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted. Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube. Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal. It was then left in situ. Hemostasis was achieved in the pelvis with the use of electrocautery. The abdomen and pelvis were copiously irrigated with warm saline solution. The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle. The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen. The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly. Excellent closure of the incision was noted. The subcutaneous tissues were then copiously irrigated. Hemostasis was achieved with the use of cautery. Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture. The skin was closed with staples.,Incision was sterilely clean and dressed. The patient was awakened from general anesthesia and taken to the recovery room in stable condition. All counts were noted correct times three.
## 634 PREOPERATIVE DIAGNOSIS:, History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES: ,1. History of perforated sigmoid diverticuli with Hartmann's procedure.,2. Massive adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions and removal.,3. Reversal of Hartmann's colostomy.,4. Flexible sigmoidoscopy.,5. Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula. Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE: ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion. A cystoscope was introduced into the patient's urethra and to the bladder. Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra. The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley. At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline. Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall. Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall. Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis. At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats. The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made. First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well. Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound. Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired. The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied. Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum. The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it. The EEA was then fired. Once it was fired and was removed, the pelvis was filled with fluid. Immediately both doughnuts were ____ from the anastomosis. A Doyen was placed in both the anastomosis. Colonoscope was introduced. No bubble or air was seen coming from the anastomosis. There was no evidence of bleeding. Pictures of the anastomosis were taken. The scope then was removed from the patient's rectum. Copious amount of irrigation was used within the peritoneal cavity. Immediately at this point, all complete sponge and instrument count was performed. First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture. The peritoneum was closed with running #2-0 Vicryl suture. Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle. Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well. The patient did tolerate the procedure well and will be followed during the hospitalization. The left ureteral stent was removed at the end of the procedure. _____ were performed. Lysis of adhesions were performed. Reversal of colostomy and EEA anastomosis #29 Ethicon.
## 635 PREOPERATIVE DIAGNOSIS:, Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED: ,Repair of left little extensor tendon.,COMPLICATIONS:, None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year-old right-hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operative room, laid supine, administered intervenous sedation with Bier block and prepped and draped in a sterile fashion. The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon, which is essentially in line with the tendon fibers. This was just proximal to the PIP joint and on complete flexion of the PIP joint, I did separate just a little bit that was not thought to be significantly dynamically unstable. It was sutured with a single 4-0 Prolene interrupted figure-of-eight suture and on dynamic motion it did not separate at all. The wound was irrigated and closed with 5-0 nylon interrupted sutures. The patient tolerated the procedure well and was taken to the PCU in good condition.
## 636 PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1. Colovesical fistula.,2. Intraperitoneal abscess.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Low anterior colon resection.,3. Flexible colonoscopy.,4. Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY: ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra. The patient had retrograde cystogram, which revealed colovesical fistula. Recommendation for a surgery was made. The patient was explained the risks and benefits as well as the two sons and the daughter. They understood that the patient can even die from this procedure. All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic. An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker. Electrocautery was used for hemostasis down to the fascia. The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall. At this point, immediately a small bowel was retracted cephalad. The patient was taken to a slightly Trendelenburg position and the descending colon was seen. The white line of Toldt was opened all the way down to the area of inflammation. At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess. When the small bowel was completely freed of abscess, bulk of the bladder was seen anteriorly to the uterus. The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized. At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum. At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed. Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired. The specimen was cut with #10 blade Bard-Parker and sent it to Pathology. Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis. A pursestring device was fired. The staple line was cut. The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied. At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced. The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient. ,Immediately, the EEA was connected with a mushroom. It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches. Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air. No air was seen evolving from the staple line. All fluid was removed and pictures of the staple line were taken. The scope was removed at this point. The case was passed to Dr. X for repair of the vesicle fistula. Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon. After this was performed, copious amount of irrigation was used again. More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area. The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin. The wire was passed under the transverse colon. It was left in place. Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis. At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied. Electrocautery for hemostasis and the subcutaneous tissue. Copious amount of irrigation was used. The skin was approximated with staples. At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made. The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge. One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened. As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture. The JP was secured with #3-0 nylon suture as well. At this point, dressings were applied. The patient tolerated the procedure well. The stent from the left ureter was removed and the Foley was left in place. The patient did tolerate the procedure well and will be followed up during the hospitalization.
## 637 PREOPERATIVE DIAGNOSIS:,1. Acute bowel obstruction.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1. Acute small bowel obstruction.,2. Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Release of small bowel obstruction.,3. Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:, None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY: ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction. Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia. There was a loop of small bowel incarcerated within the hernia sac. It showed signs of ecchymosis, however no signs of any ischemia or necrosis. It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family. The patient was brought to the operating suite. After general endotracheal intubation, prepped and draped in normal sterile fashion. A midline incision was made around the umbilical hernia defect with a #10 blade scalpel. Dissection was then carried down to the fascia. Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia. The abdomen was entered under direct visualization. The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis. The remaining of the fascia was then extended using Metzenbaum scissors. The hernia sac was removed using Mayo scissors and sent off as specimen. Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities. The small bowel was then milked down removing all the fluid. The bowel was decompressed distal to the obstruction. Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed. The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture. A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin. Sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition.
## 638 PREOPERATIVE DIAGNOSES:,1. Enlarging nevus of the left upper cheek.,2. Enlarging nevus 0.5 x 1 cm, left lower cheek.,3. Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1. Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2. Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3. Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,ANESTHESIA: ,Local. I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,COMPLICATIONS:, None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed. Each of these lesions appears to be benign nevi; however, they have been increasing in size. The lesions involving the left upper and lower cheek appear to be deep. These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision. Each of these lesions was marked. The skin was cleaned with a sterile alcohol swab. Local anesthetic was infiltrated. Sterile prep and drape were then performed.,Began first excision of the left upper cheek skin lesion. This was excised with the 15-blade full thickness. Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,The lesion of the lower cheek was removed in a similar manner. Again, it was excised with a 15 blade with two layer plastic closure. Both these lesions appear to be fairly deep nevi.,The right nasal ala nevus was superficially shaved using the radiofrequency wave unit. Each of these lesions was sent as separate specimens. The patient was discharged from my office in stable condition. He had minimal blood loss. The patient tolerated the procedure very well. Postop care instructions were reviewed in detail. We have scheduled a recheck in one week and we will make further recommendations at that time.
## 639 PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:, Local with monitored anesthesia care.,INDICATIONS:, Patient, 72, status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb. The deep margin was positive. Other margins were clear. He was brought back for re-excision.,PROCEDURE:, The patient was brought to the operating room and placed in the supine position. He was given intravenous sedation. The right hand was prepped and draped in the usual sterile fashion. Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath. The tissue was passed off the field as a specimen.,The wound was irrigated with warm normal saline. Hemostasis was assured with the electrocautery. The wound was closed with running 3-0 nylon without complication. The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.
## 640 PREOPERATIVE DIAGNOSES:,1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5. A 1 cm x 1 cm actinic keratosis of the right mid cheek.,POSTOPERATIVE DIAGNOSES:,1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5. A 1 cm x 1 cm actinic keratosis of the right mid cheek.,TITLE OF PROCEDURES:,1. Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.,2. Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.,3. Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.,4. Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.,5. A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.,ANESTHESIA: , Local. I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS:, Less than 30 mL.,COMPLICATIONS: , None.,COUNTS: ,Sponge and needle counts were all correct.,PROCEDURE:, The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. She is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc. The areas of concern were marked with the marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.,I began excising the left upper cheek and left lower cheek neck lesions as listed above. These were excised with the #15 blade. The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm. A suture was placed at the 12 o'clock superior margin. Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma. The healthy margin of healthy tissue around this lesion was removed. Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The left upper neck lesion was also removed in the similar manner. This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis. It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm. After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit. These appeared to be clinically seborrheic keratotic neoplasms.,Finally proceeded with the right cheek lesion, which was treated with the 50% TCA. This was also an actinic keratosis. It is new in onset, just within the last week. Once a light frosting was obtained from the treatment site, bacitracin ointment was applied. Postop care instructions have been reviewed in detail. The patient is scheduled a recheck in one week for suture removal. We will make further recommendations at that time.
## 641 PREOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1. Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2. Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3. Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:, None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition. Informed consent was obtained from the patient. All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient. This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc. Each of the areas was cleaned with a sterile alcohol swab. Planned excision site was marked with a marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions. The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm. However, it is somewhat deeper than the standard seborrheic keratosis. The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region. Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus. It was excised with a defect 0.5 x 0.5 cm. It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension. Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm. Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin. Sterile dressing was applied afterwards. The patient was discharged in stable condition. Postop care instructions reviewed in detail. She is scheduled with me in one week and we will make further recommendations at that time.
## 642 PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:, This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.,DESCRIPTION OF PROCEDURE:, Consent was obtained after all risks and benefits were described. The patient was brought back into the operating room. The aforementioned anesthesia was given. Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion. With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank. Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass. The incision was extended down using electrocautery. The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle. The mass was sent off to Pathology for investigation. Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion. The patient's wound was cleaned. Steri-Strips were placed and sterile dressings were placed on top of this. The patient tolerated the procedure well and will reevaluate in the office in one week's time.
## 643 PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: , Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:, None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE: , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact. The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications.
## 644 PROCEDURES PERFORMED:,1. Functional endoscopic sinus surgery.,2. Bilateral maxillary antrostomy.,3. Bilateral total ethmoidectomy.,4. Bilateral nasal polypectomy.,5. Right middle turbinate reduction.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS:, Approximately 50 cc.,INDICATION: , This is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management. She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,PROCEDURE: ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained. The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity. The nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution. The patient was then prepped and draped in the usual fashion.,Attention was directed first to the left nasal cavity. A zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx. The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate. There was also polypoid disease present within the left middle meatus. Nasopharynx was visualized with a patent eustachian tube. At this point, the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate. The ostium to the sphenoid sinus was visualized and was not entered. At this point, the left middle turbinate was localized and then medialized with the use of a freer elevator. A ball-tip probe was then used to localize the openings for the natural maxillary ostium. Side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider. The opening of the maxillary sinus was visualized. The posterior fontanelle was taken down with the use of straight line forceps. It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident. The maxillary sinus ostia was then suctioned with Olive-tip suction and maxillary wash was performed. The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue. The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration. All polypoid tissue was collected in the microdebrider and sent as a surgical specimen. Once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes. Attention was then directed to the right nasal cavity. Again, a sinus endoscope was inserted. Inspection revealed a grossly hypertrophied turbinate. It was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms. Therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the Takahashi forceps. Sinus endoscope was then inserted all the way down through the nasopharynx. Again, the eustachian tube was visualized without any obstructing lesions or masses. Upon retraction, there was again polypoid tissue noted within the ethmoid sinuses. The ball-tip probe was again used to locate the right maxillary ostium. The side-biting forceps was used further take down the uncinate process. The maxillary ostium was then widened with use of a XPS microdebrider. A maxillary sinus wash was then performed. Now, the attention was directed to the ethmoid air cells. It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid. This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient's eye.,Once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner. Once all bleeding has been controlled, all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room. At this point, the procedure was felt to be complete. The patient was awakened and taken to the recovery room without incident.
## 645 PRIMARY DIAGNOSIS:, Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:, Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:, Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed. Esophagus was visualized. The quarter was visualized at the aortic knob, was removed with grasper. Estimated blood loss 0. Intravenous fluids during time of procedure 100 mL. No tissues. No complications. The patient tolerated the procedure well. Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure. The patient was transferred from OR to PACU in stable condition.
## 646 PREOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,POSTOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,NAME OF OPERATION: , Excision of bilateral chronic hydradenitis.,ANESTHESIA:, Local.,FINDINGS: , This patient had previously had excision of hydradenitis. However, she had residual disease in both axilla with chronic redraining of the cyst from hydradenitis. This now is controlled and it was found to be suitable for excision. There was an area in each axilla which needed to be excised.,PROCEDURE: , Under local infiltration and after routine prepping and draping, an elliptical incision was first made on the left side to encompass the area of chronic hydradenitis. This wound was then irrigated with saline. The deeper layers were closed using interrupted 3-0 Vicryl. The skin was closed using interrupted 5-0 nylon.,Attention was then directed to the right side where a similar procedure was carried out encompassing the involved area with the closure being identical to the opposite side. This appeared to encompass all of the active area of hydradenitis.,The needle counts were all correct. No intraoperative complications were encountered. Dressings were applied, and the patient was returned to the recovery room in satisfactory condition.
## 647 PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1. Hiatal hernia.,2. Reflux esophagitis.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:, Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:, The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough. She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite. She was placed in the left lateral position and was given IV Demerol and Versed for sedation. When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated. At the GE junction, a hiatal hernia was present. There were mild inflammatory changes consistent with reflux esophagitis. The scope was then passed into the stomach. It was insufflated and the scope was coursed along the greater curvature to the antrum. The pylorus was patent. There was evidence of bile reflux in the antrum. The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation. The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized. The gastroscope was then slowly withdrawn. There were no other abnormalities noted in the fundus or body. Once again at the GE junction, esophageal biopsy was taken. The scope was then completely withdrawn. The patient tolerated the procedure and was transferred to the recovery room in stable condition. She will return to the General Medical Floor. We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions. She should also attempt significant weight loss.
## 648 PROCEDURE: , Esophagogastroduodenoscopy with gastric biopsies.,INDICATION:, Abdominal pain.,FINDINGS:, Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,MEDICATIONS: , Fentanyl 200 mcg and versed 6 mg.,SCOPE: , GIF-Q180.,PROCEDURE DETAIL: , Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation and side effects of medications and alternatives were reviewed. Questions were answered. Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty. The esophagus appeared to have normal motility and mucosa. Regular Z line was located at 44 cm from incisors. No erosion or ulceration. No esophagitis.,Upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus. There was pyloric channel and antral erythema, but no visible erosion or ulceration. There was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp. This was biopsied and was placed separately in bottle #2. Random gastric biopsies from antrum, incisura and body were obtained and placed in separate jar, bottle #1. No active ulceration was found.,Upon entering the duodenal bulb there was extensive erythema and mild erosions, less than 3 mm in length, in first portion of duodenum, duodenal bulb and junction of first and second part of the duodenum. Postbulbar duodenum looked normal.,The patient was assessed upon completion of the procedure. Okay to discharge once criteria met.,Follow up with primary care physician.,I met with patient afterward and discussed with him avoiding any nonsteroidal anti-inflammatory medication. Await biopsy results.
## 649 PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:, Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed. The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD. The patient is fed by mouth and also with nasogastric enteral feeding supplements. She has had an __________ cough and relatively disinterested in oral intake for the past month. She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted. Based on the history, it is quite possible this coin has been there close to a month. She is brought to the operating room now for attempted removal. I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time. Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location. There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive. The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia. She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications. After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism. A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view. This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen. At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps. I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved. The patient tolerated the procedure well. There were no intraoperative complications. There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.
## 650 PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:, Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery. The patient was brought to the GI lab. There, she was placed in partial left lateral decubitus position. She was given IV sedation by Anesthesia. Her abdomen was prepped with alcohol and then Betadine. Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum. No lesions were noted in the duodenum. There appeared to be a few polyps in the antral area, two in the antrum. Actually, one appeared to be almost covering the pylorus. The scope was withdrawn back into the antrum. On retroflexion, we could see a large hiatal hernia. No other lesions were noted. Biopsy was taken of one of the polyps. The scope was left in position. Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area. A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth. Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall. It was held in position with a dressing and a stent. A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature. The patient tolerated the procedure well. She was returned to the floor in stable condition.
## 651 PREOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1. Esophagogastroduodenoscopy with photo.,2. Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:, IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY: ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA. The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure. The patient also had neuromuscular dysfunction. After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family. First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus. Esophagitis was noted. The scope was then passed through the esophagus into the stomach. The cardia, fundus, body, and antrum of the stomach were visualized. There was evidence of gastritis. The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus. Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement. The skin was then anesthetized with 1% lidocaine. The finder needle was then inserted under direct visualization. The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth. The Ponsky PEG tube was attached to the wire. A skin nick was made with a #11 blade scalpel. The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position. The endoscope was then replaced confirming position. Photograph was taken. The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well. We will begin tube feeds later this afternoon.
## 652 PREOPERATIVE DIAGNOSIS:, Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:, Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:, The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted. Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses. The profundus and the cardia of the stomach were unremarkable. The pylorus was concentric. The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position. She was given IV sedation using Demerol and Versed. Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus. Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep. The above gross findings noted. The panendoscope was withdrawn back from the stomach, deflected upon itself. The lesser curve fundus and cardiac were well visualized. Upon examination of these areas, panendoscope was returned to midline. Photographs and biopsies were obtained of the antrum of the stomach. Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate. The patient is sent to recovery room in stable condition.
## 653 PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,3. Alkaline reflux gastritis.,4. Gastroparesis.,5. Probable Billroth II anastomosis.,6. Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass. The patient has pancreatic insufficiency and is already on replacement. She is currently using Nexium. She has continued postprandial dyspepsia and reflux symptoms. To evaluate this, the patient was boarded for EGD. The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis. There was no evidence of distal esophagitis. Gastroparesis was seen as there was retained fluid in the small intestine. The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy. Biopsies were taken and further recommendations will follow.,PROCEDURE: ,The patient was taken to the Endoscopy Suite. The heart and lungs examination were unremarkable. The vital signs were monitored and found to be stable throughout the procedure. The patient's oropharynx was anesthetized with Cetacaine spray. She was placed in left lateral position. The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx. GE junction was in normal position. There was no evidence of any hiatal hernia. There was no evidence of distal esophagitis. The gastric remnant was entered. It was noted to be inflamed with alkaline reflux gastritis. The anastomosis was open and patent. The small intestine was entered. There was retained fluid material in the stomach and small intestine and _______ gastroparesis. Biopsies were performed. Insufflated air was removed with withdrawal of the scope. The patient's diet will be adjusted to postgastrectomy-type diet. Biopsies performed. Diet will be reviewed. The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis. Reglan will also be added. Further recommendations will follow.
## 654 PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Duodenal polyp.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described. The patient was brought back into the Endoscopy Suite. The aforementioned anesthesia was given. Once the patient was properly anesthetized, bite block was placed in the patient's mouth. Then, the patient was given the aforementioned anesthesia. Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach. The air was insufflated down. The scope was passed down to the level of the antrum where there was some evidence of gastritis seen. The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen. The scope was pulled back into the stomach in order to flex upon itself and straightened out. Biopsies were taken for CLO and histology of the antrum. The scope was pulled back. The junction was visualized. No other masses or lesions were seen. The scope was removed. The patient tolerated the procedure well. We will recommend the patient be on some type of a H2 blocker. Further recommendations to follow.
## 655 PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum. The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal. No evidence of friability, ulceration or tumor mass was encountered. The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed.
## 656 PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage. Currently, he has a fistula from his anterior abdominal wall out. It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall. CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease. Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS: ,General anesthesia.,INSTRUMENT:, Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia. The endoscope was inserted without difficulty into the hypopharynx. The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern. Lower esophageal sphincter was located at 40 cm from the central incisors. It appeared normal and appeared to function normally. The endoscope was advanced into the stomach, which was distended with excess air. Rugal folds were flattened completely. There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach. The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern. Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology. Two additional biopsies were obtained in the antrum for CLO testing. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy. Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock. The colonoscope was then inserted into the anal verge. The colonic clean out was excellent. The scope was advanced without difficulty to the cecum. The cecal area had multiple ulcers with exudate. The ileocecal valve was markedly distorted. Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum. The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon. Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm. No fistulas were noted in the colon. Excess air was evacuated from the colon. The scope was removed. The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum. There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve. All these findings are consistent with Crohn's disease.,PLAN: ,Begin prednisone 30 mg p.o. daily. Await PPD results and chest x-ray results, as well as cocci serology results. If these are normal, then we would recommend Remicade 5 mg/kg IV infusion. We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy. Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate. We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula. He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy. If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.
## 657 MEDICATIONS:,1. Versed intravenously.,2. Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx. The patient was sedated with the above medications. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. The scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air. The gastric mucosa appeared normal. The pylorus was normal. The scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well. The scope was pulled back into the stomach. Retroflexed view showed a normal incisura, lesser curvature, cardia and fundus. The scope was straightened out, the air removed and the scope withdrawn. The patient tolerated the procedure well. There were no apparent complications.,
## 658 PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1. Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2. Endoscopy following erythromycin demonstrated grade I esophageal varices. No stigmata of active bleeding. Small amount of fresh blood within the hiatal hernia. No definite source of bleeding seen.,PLAN,1. Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2. Proton-pump inhibitor drip.,3. Octreotide drip.,4. ICU bed.,PROCEDURE DETAILS: ,Prior to the procedure, physical exam was stable. During the procedure, vital signs remained within normal limits. Prior to sedation, informed consent was obtained. Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks. The patient was prepped in the left lateral position. IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD. An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin. Scope tip of the Olympus gastroscope was passed into the esophagus. Proximal, middle, and distal thirds of the esophagus were well visualized. There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen. No evidence of varices was seen. The stomach was entered. The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden. There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden. Because of this, the gastroscope was withdrawn. The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed. On the second look, the esophagus was cleared. The liquid gastric contents were cleared. There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen. There was a small grade I esophageal varices, but no stigmata of bleed. There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified. The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning. The scope was withdrawn and air was suctioned. The patient tolerated the procedure well and was sent to recovery without immediate complications.
## 659 PROCEDURES:, Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:, History and physical examination was performed. The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this. Opportunity for questions was provided and informed consent was obtained.,MEDICATION: ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:, None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx. The esophageal mucosa and vascular pattern appeared normal. The lower esophageal sphincter was located at 25 cm from the central incisors. It appeared normal. A Z-line was identified within the lower esophageal sphincter. The endoscope was advanced into the stomach, which distended with excess air. Rugal folds flattened completely. Gastric mucosa appeared normal throughout. No hiatal hernia was noted. Pyloric valve appeared normal. The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern. Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology. Additional 2 biopsies were obtained for CLO testing in the antrum. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated that part of procedure well. The patient was turned and the scope was advanced with some difficulty to the terminal ileum. The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted. Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum. Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3. The polyp was severed. There was no bleeding at the stalk after removal of the polyp head. The polyp head was removed by suction. Excess air was evacuated from the colon. The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition. Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN: ,Histologic evaluation and CLO testing. I will contact the parents next week with biopsy results and further management plans will be discussed at that time.
## 660 PROCEDURE:, Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:, The child with history of irritability and diarrhea with gastroesophageal reflux. Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease. He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed. The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this. Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS: ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx. The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern. Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors. A Z-line was identified within the lower esophageal sphincter. The endoscope was advanced into the stomach, which was distended with excess air. The rugal folds flattened completely. The gastric mucosa was entirely normal. No hiatal hernia was seen and the pyloric valve appeared normal. The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern. Ampule of Vater was identified and found to be normal. Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology. Additional two antral biopsies were obtained for CLO testing. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated the procedure well. The patient was taken to recovery room in satisfactory condition.,IMPRESSION:, Normal esophagus, stomach, and duodenum.,PLAN:, Histologic evaluation and CLO testing. Continue Prevacid 7.5 mg p.o. b.i.d. I will contact the parents next week with biopsy results and further management plans will be discussed at that time.
## 661 PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,3. Enterogastritis.,PROCEDURE PERFORMED: ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdominal pain, persistent in nature. She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently. She has had a history of hiatal hernia. She is being evaluated at this time for disease process. She does not have much response from Protonix.,Upon endoscopy, the gastroesophageal junction is approximately 40 cm. There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia. There is no advancement of the gastric mucosa up into the lower one-third of the esophagus. However there appeared to be inflammation as stated previously in the gastroesophageal junction. There was some mild inflammation at the antrum of the stomach. The fundus of the stomach was within normal limits. The cardia showed some laxity to the lower esophageal sphincter. The pylorus is concentric. The duodenal bulb and sweep are within normal limits. No ulcers or erosions.,OPERATIVE PROCEDURE: , The patient is taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position. The patient was given IV sedation using Demerol and Versed. Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus. Using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted. Panendoscope was slowly withdrawn carefully examining the lumen of the bowel. Photographs were taken with the pathology present. Biopsy was obtained of the antrum of the stomach and also CLO test. The biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult Barrett's esophagitis. Air was aspirated from the stomach and the panendoscope was removed. The patient sent to recovery room in stable condition.
## 662 PREOPERATIVE DIAGNOSIS:, Recurrent right upper quadrant pain with failure of antacid medical therapy.,POSTOPERATIVE DIAGNOSIS: , Normal esophageal gastroduodenoscopy.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with bile aspirate.,ANESTHESIA: , IV Demerol and Versed in titrated fashion.,INDICATIONS: , This 41-year-old female presents to surgical office with history of recurrent right upper quadrant abdominal pain. Despite antacid therapy, the patient's pain has continued. Additional findings were concerning with possibility of a biliary etiology. The patient was explained the risks and benefits of an EGD as well as a Meltzer-Lyon test where upon bile aspiration was performed. The patient agreed to the procedure and informed consent was obtained.,GROSS FINDINGS: , No evidence of neoplasia, mucosal change, or ulcer on examination. Aspiration of the bile was done after the administration of 3 mcg of Kinevac.,PROCEDURE DETAILS: , The patient was placed in the supine position. After appropriate anesthesia was obtained, an Olympus gastroscope inserted from the oropharynx through the second portion of duodenum. Prior to this, 3 mcg of IV Kinevac was given to the patient to aid with the stimulation of bile. At this time, the patient as well complained of epigastric discomfort and nausea. This pain was similar to her previous pain.,Bile was aspirated with a trap to enable the collection of the fluid. This fluid was then sent to lab for evaluation for crystals. Next, photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease, retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________, gastroscope was retracted. The gastroesophageal junction was noted at 20 cm. No other evidence of disease was appreciated here. Retraction of the gastroscope backed through the esophagus, off the oropharynx, removed from the patient. The patient tolerated the procedure well. We will await evaluation of bile aspirate.
## 663 PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids. The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS: ,The procedure was done under general anesthesia given by Dr. Marino Fernandez.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL:, A history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure. The opportunity for questions was provided, and informed consent was obtained. Once the consent was obtained, the patient was sedated with IV medications and intubated by Dr. Fernandez and placed in the supine position. Then, the tip of the XP-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus. We did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose. Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum. We noticed that the patient had several ulcers in the first portion of the duodenum. Then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there. Then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for CLOtest. By retroflexed view, at the level of the body of the stomach, I could see that the patient had the lower esophageal sphincter loose. Finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken. At the end, air was suctioned from the stomach, and the endoscope was removed out of the patient's mouth. The patient tolerated the procedure well with no complications.,FINAL IMPRESSION: ,1. Duodenal ulcers.,2. Loose lower esophageal sphincter.,PLAN:,1. To start omeprazole 20 mg a day.,2. To review the biopsies.,3. To return the patient back to clinic in 1 to 2 weeks.
## 664 PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.
## 665 OPERATION,1. Ivor-Lewis esophagogastrectomy.,2. Feeding jejunostomy.,3. Placement of two right-sided #28-French chest tubes.,4. Right thoracotomy.,ANESTHESIA: ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Prior to administration of general anesthesia, the patient had an epidural anesthesia placed. In addition, he had a dual-lumen endotracheal tube placed. The patient was placed in the supine position to begin the procedure. His abdomen and chest were prepped and draped in the standard surgical fashion. After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus. Dissection was carried down through the linea using Bovie electrocautery. The abdomen was opened. Next, a Balfour retractor was positioned as well as a mechanical retractor. Next, our attention was turned to freeing up the stomach. In an attempt to do so, we identified the right gastroepiploic artery and arcade. We incised the omentum and retracted it off the stomach and gastroepiploic arcade. The omentum was divided using suture ligature with 2-0 silk. We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk. Next, we turned our attention to performing a Kocher maneuver. This was done and the stomach was freed up. We took down the falciform ligament as well as the caudate attachment to the diaphragm. We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest. We also did a portion of the esophageal dissection from the abdomen into the chest area. The esophagus and the esophageal hiatus were identified in the abdomen. We next turned our attention to the left gastric artery. The left gastric artery was identified at the base of the stomach. We first took the left gastric vein by ligating and dividing it using 0 silk ties. The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement. At this point the stomach was freely mobile. We then turned our attention to performing our jejunostomy feeding tube. A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz. We then used Bovie electrocautery to open the jejunum at this site. We placed a 16-French red rubber catheter through this site. We tied down in place. We then used 3-0 silk sutures to perform a Witzel. Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties. After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen. This was done with #1 Prolene. We put in a 2nd layer of 2-0 Vicryl. The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure. The patient was placed in the left lateral decubitus position. The right chest was prepped and draped appropriately. We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion. Dissection was carried down to the level of the ribs with Bovie electrocautery. Next, the ribs were counted and the 5th interspace was entered. The lung was deflated. We placed standard chest retractors. Next, we incised the peritoneum over the esophagus. We dissected the esophagus to just above the azygos vein. The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties. As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus. After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring. We used an automatic pursestring and applied. We then transected the proximal portion of the stomach with Metzenbaum scissors. We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus. The pursestring was then tied down without difficulty. Next, we tabularized our stomach using a #80 GIA stapler. After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery. We placed our EEA stapler through it and then punched out through the gastric wall. We connected our anvil to the EEA stapler. This was then secured appropriately. We checked to make sure that there was appropriate muscle apposition. We then fired the stapler. We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology. We also sent the gastroesophageal specimen for pathology. Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins. We then turned our attention to closing the gastrostomy opening. This was closed with 2-0 Vicryl in a running fashion. We then buttressed this with serosal 3-0 Vicryl interrupted sutures. We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it. Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis. We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion. The lung was brought up. We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.
## 666 PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:, Esophageal foreign body.,PROCEDURES PERFORMED:,1. Direct laryngoscopy with intubation by surgeon.,2. Rigid tracheoscopy.,3. Rigid esophagoscopy with removal of foreign body.,INDICATIONS: , The patient is an 8-month-old Hispanic male, who presented to the Emergency Department with approximately 12-hour history of choking event and presumed for esophageal foreign body. When seen in the Emergency Department, he was having no difficulty managing his secretions or any signs of any airway compromise. Imaging in the Emergency Department did demonstrate an esophageal foreign body at or above the level of the cricopharyngeus. Due to this, the patient was consented and taken urgently to the operating room for removal of this foreign body.,OPERATIVE DETAILS:, The patient was correctly identified in the preop holding area and brought to operating room #37. After informed consent was reviewed, general anesthesia was induced, initially with propofol, the existing IV. Following this after protective eye tape was placed, #9 Parson's laryngoscope was introduced transorally and used to perform a direct laryngoscopy. Normal anatomy was visualized. Following this, a 4-mm, 20-rigid endoscope was introduced through the Parson's laryngoscope and used to perform a direct tracheoscopy. The patient's supraglottis, glottis, and subglottis down to the level of the mid trachea were found to be benign with no abnormal-appearing anatomy. Following this, the rigid endoscope was removed and the patient was intubated with a 4-0 endotracheal tube cuffed without difficulty. After confirming bilateral breath sounds and positive end tidal CO2, this was secured to the patient by the anesthesia staff. Following this, the Parson's laryngoscope was removed and a size 4 rigid esophagoscope was inserted transorally and passed down to the level of the patient's cricopharyngeus were the foreign body was visualized. At this point, the coin grasper device was connected to the camera system and inserted through the existing esophagoscope. This was used to grasp the coin and the coin was removed under direct visualization and handed off as a separate specimen. Following this, the 34 mm 0-degree scope was inserted through the esophagoscope once the esophagoscope was passed down to the patient's GE junction. The entire esophageal mucosa was examined as the esophagoscope was backed out and there was only a minimal amount of superficial ulceration in the posterior wall of the esophagus near the level of the cricopharyngeus muscle. There were no other lesions or signs of further esophageal damage. Following this, all instrumentation was removed, and care of the patient was turned back to the anesthesia staff for stable wakeup.,FINDINGS:,1. Normal supraglottic, glottic, and subglottic anatomy.,2. Esophageal foreign body at the level of the cricopharyngeus.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, None.,DISPOSITION: , Stable to the PACU and then home.
## 667 PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS: ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:, IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite. After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus. A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus. The first, second, and third portions of the duodenum were normal. The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori. The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia. The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone. The scope was then removed throughout the esophagus which was normal. The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.
## 668 PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE: ,After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.
## 669 PREOPERATIVE DIAGNOSES:, 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,PROCEDURES PERFORMED:,1. Lateral escharotomy of right upper arm burn eschar.,2. Medial escharotomy of left upper extremity burns and eschar.,ANESTHESIA:, Propofol and Versed.,INDICATIONS FOR PROCEDURE: , The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax. The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity. The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity. It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.,DESCRIPTION OF PROCEDURE:, After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position. An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity. Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue. The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity. All dermal bridging was taken down and was opened without any excessive bleeding. Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity. Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue. All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down. At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer. Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix. The patient tolerated the procedure well, and there were no adverse events during or after the procedure.
## 670 PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:, Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely. The hernia mass had been marked preoperatively. This area was anesthetized with a mixture of Marcaine and Xylocaine. A transverse incision was made over the hernia and dissection carried down to the entrapped fat. Sharp dissection was carried around the fat down to the fascial edge. The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures. The fascial edges were injected with the local anesthetic mixture. Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl. Steri-Strips and a sterile dressing were applied to complete the closure. The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None.
## 671 EPIDIDYMECTOMY,OPERATIVE NOTE: ,The patient was placed in the supine position and prepped and draped in the usual manner. A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened. A small amount of clear fluid was expressed. The tunica vaginalis was opened and the testicle was brought out through this incision. The epididymis was separated off the surface of the testicle using a scalpel. With blunt and sharp dissection, the epididymis was dissected off the testicle. Bovie was used for hemostasis. The vessels going to the testicle were preserved without any obvious injury, and a nice viable testicle was present after the epididymis was removed from this. The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also. There was no obvious bleeding. The cord was infiltrated with 0.25% Marcaine, as was the dartos tissue in the scrotum. The testicle was replaced in the scrotum. Skin was closed in two layers using 3-0 chromic catgut for the dartos and a subcuticular closure with the same material. A dry sterile dressing and compression were applied, and he was sent to the recovery room in stable condition.
## 672 PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE: ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium. He was intubated in a single attempt. Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade. Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture. A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes. The patient tolerated the procedure well.
## 673 PREOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:, A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1. Epidermal autograft on Integra to the back (3520 cm2).,2. Application of allograft to areas of the lost Integra, not grafted on the back (970 cm2).,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, Approximately 50 cc.,BLOOD PRODUCTS RECEIVED:, One unit of packed red blood cells.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities. He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands. His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites, the extent they will provide coverage.,OPERATIVE FINDINGS:,1. Variable take of Integra, particularly centrally and inferiorly on the back. A fair amount of lost Integra over the upper back and shoulders.,2. No evidence of infection.,3. Healthy viable wound beds prior to grafting.,PROCEDURE IN DETAIL:, The patient was brought to the operating room and positioned supine. General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed. He was then repositioned prone and perioperative IV antibiotics were administered. He was prepped and draped in the usual sterile manner. All staples were removed from the Integra and the adherent areas of Silastic were removed. The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution. Hemostasis of the wound bed was ensured using epinephrine-soaked Telfa pads. Following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air Zimmer dermatome. These grafts were passed to the back table where they were meshed 3:1. The donor sites were hemostased using epinephrine-soaked Telfa and lap pads. Once all the grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment. We were happy with the lie of the grafts and they were stapled into place. The grafts were then overlaid with Conformant 2, which was also stapled into place. Utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment. Allograft was thawed and meshed 1:1. It was then brought up onto the field, trimmed to fit and stapled into place over the wound. Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied. Donor sites on his buttocks were dressed in Acticoat and secured with staples. He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications. He was transported to PACU in stable condition.
## 674 PREOPERATIVE DIAGNOSES:,1. Epidural hematoma, cervical spine.,2. Status post cervical laminectomy, C3 through C7 postop day #10.,3. Central cord syndrome.,4. Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1. Epidural hematoma, cervical spine.,2. Status post cervical laminectomy, C3 through C7 postop day #10.,3. Central cord syndrome.,4. Acute quadriplegia.,PROCEDURE PERFORMED:,1. Evacuation of epidural hematoma.,2. Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,200 cc.,HISTORY: ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction. She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess. The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change. The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement. Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing. When she examined the patient, she also noted that the patient was unable to move her extremities. She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic. I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma. On clinical examination, there was swelling in the posterior aspect of the neck. The patient has no active movement in the upper and lower extremity muscle groups. Reflexes are absent in the upper and lower extremities. Long track signs are absent. Sensory level is at the C4 dermatome. Rectal tone is absent. I discussed the findings with the patient and also the daughter. We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery. They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE: ,The patient was taken to OR #1 at ABCD General Hospital on a gurney. Department of Anesthesia administered fiberoptic intubation and general anesthetic. A Foley catheter was placed in the bladder. The patient was log rolled in a prone position on the Jackson table. Bony prominences were well padded. The patient's head was placed in the prone view anesthesia head holder. At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound. Next, the patient was prepped and draped in the usual sterile fashion. The previous skin incision was reopened. At this point, hematoma properly exits from the wound. All sutures were removed and the epidural spaces were encountered at this time. The self-retaining retractors were placed in the depth of the wound. Consolidated hematoma was now removed from the wound. Next, the epidural space was encountered. There was no additional hematoma in the epidural space or on the thecal sac. A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac. The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well. Next, the wound was irrigated copiously with one liter of saline using a syringe. The walls of the wound were explored. There was no active bleeding. Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding. A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space. Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures. Steri-Strips covered the incision and dressing was then applied over the incision. The patient was then log rolled in the supine position on the hospital gurney. She remained intubated for airway precautions and transferred to the recovery room in stable condition. Once in the recovery room, she was alert. She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities. Prognosis for this patient is guarded.
## 675 PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:, Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm. A Gore exclusive device was used 3 pieces were used to effect the repair. We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm. The right hypogastric artery had been previously coiled off. Left common femoral artery was used for the _____ side. We had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area. It was felt that this would seal after reversal of the anticoagulation given sufficient time.,PROCEDURE: , With the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,Bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally. The patient was then heparinized.,The 7-French sheaths were then placed retrograde bilaterally.,A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side. The calibrated aortogram was the done. We marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries. We then preceded placement of the main trunk, by replacing the 7 French sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery. As noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,Following completion of the above all arteries were ballooned appropriately. A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries. The area was ballooned aggressively. It was felt that this would dissolve as discussed above.,Following completion of the above all wire sheaths etc., were removed from both groin areas. Both femoral arteries were repaired by primary suture technique. Flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,Both surgical sites were then irrigated thoroughly. Meticulous hemostasis was achieved. Both wounds were then closed in a routine layered fashion.,Sterile antibiotic dressings were applied. Sponge and needle counts were reported as correct. The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition.
## 676 PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. He has been on Coumadin for previous PE and currently on heparin drip. He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness. A code blue was called. On my arrival, the patient's vital signs are stable. His blood pressure is systolically in 140s and heart rate 80s. He however has 0 respiratory effort and is unresponsive to even painful stimuli. The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE: ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine. Mac-4 blade was used. A 7.5 ET tube placed to 24th teeth. There is good color change on the capnographer with bilateral breath sounds. Following intubation, the patient's blood pressure began to drop. He was given 2 L of bolus. I started him on dopamine drip at 10 mcg. Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU. Chest x-ray will be reviewed and Pulmonary will be consulted.
## 677 PREOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root. The left side was quite open; however, that was not the side of her problem. At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root. A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location. After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides. There were no complications.
## 678 PROCEDURE:, Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained. Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL: ,The patient was placed in the left lateral decubitus position. Medications were given. After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum.
## 679 PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:, Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1. Severe duodenitis.,2. Gastroesophageal junction small ulceration seen.,3. No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position. Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction. Advanced into the upper part of the stomach into the antrum. The duodenum showed extreme duodenitis and the scope was then brought back. Retroflexion was performed, which was normal. Scope was then brought back slowly. Duodenitis was seen and a little bit of ulceration seen at GE junction.,FINDING: , Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.
## 680 INDICATIONS:, Dysphagia.,PREMEDICATION:, Topical Cetacaine spray and Versed IV.,PROCEDURE:,: The scope was passed into the esophagus under direct vision. The esophageal mucosa was all unremarkable. There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis. The scope was passed on down into the stomach. The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen. The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable. The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present. The scope was then withdrawn.,IMPRESSION:, Normal upper GI endoscopy without any evidence of anatomical narrowing.
## 681 PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:, The patient was taken to the GI lab and placed in the left lateral supine position. Continuous pulse oximetry and blood pressure monitoring were in place. After informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty. With swallowing, the scope was advanced down the esophagus into the body of the stomach. The scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion. It appeared free of stricture, neoplasm, or ulceration. Samples were obtained from the antrum and prepyloric area to check for Helicobacter, rapid urease, and additional samples were sent to pathology. Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia. The scope was then slowly removed. The distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis. The remaining portion of the esophagus was normal.,IMPRESSION:, Abdominal pain. Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,RECOMMENDATIONS:, Await results of CLO testing and biopsies. Return to clinic with Dr. Spencer in 2 weeks for further discussion.
## 682 PREOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIONS PERFORMED:, Endoscopic carpal tunnel release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament, the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch. Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.
## 683 PROCEDURE:, Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1. GERD, biopsied.,2. Distal esophageal reflux-induced stricture, dilated to 18 mm.,3. Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white male with dysphagia, which has improved recently with Aciphex.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered. The oropharynx was sprayed with Cetacaine. The endoscope was passed, under direct visualization, into the esophagus. The squamocolumnar junction was irregular and edematous. Biopsies were obtained for histology. There was a mild ring at the LES, which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma. The entire gastric mucosa was normal, including a retroflexed view of the fundus. The entire duodenal mucosa was normal to the second portion. The patient tolerated the procedure well without complication.,IMPRESSION:,1. Gastroesophageal reflux disease, biopsied.,2. Distal esophageal reflux-induced stricture, dilated to 18 mm.,3. Otherwise normal upper endoscopy.,PLAN:,I will await the results of the biopsies. The patient was told to continue maintenance Aciphex and anti-reflux precautions. He will follow up with me on a p.r.n. basis.
## 684 PREOPERATIVE DIAGNOSIS: ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,OPERATIONS PERFORMED: ,1. Endoscopic carpal tunnel release.,2. de Quervain's release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,ENDOSCOPIC CARPAL TUNNEL RELEASE:, With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament, the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch. Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated to 290 mm/Hg. A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel. Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field. The first dorsal tunnel was then identified. The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release). EPB and APL tendons were inspected and found to be completely free. The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position. The tourniquet was deflated. The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well.
## 685 PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:, Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments. The GIF-160 diagnostic gastroscope used. The patient was alert during the procedure. The esophagus was intubated under direct visualization. The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted. The stomach was unremarkable. Retroflexed exam unremarkable. Duodenum not intubated in order to minimize the time spent during the procedure. The patient was alert although not combative. A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds. The balloon was then deflated. The patient became uncomfortable and a good-size adequate distal esophageal tear was noted. The scope and balloon were then withdrawn. The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed. This has been discussed with the parents. He was sent home with a prescription for omeprazole.
## 686 PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:, Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:, General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia. A #21-French cystourethroscope was inserted into the bladder. Examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice. No other lesions were noted. Using a cold punch biopsy forceps, a random biopsy was obtained. The entire area was electrofulgurated using the Bugbee electrode. The patient tolerated the procedure well and left the operating room in satisfactory condition.
## 687 PREOPERATIVE DIAGNOSIS:, Melena.,POSTOPERATIVE DIAGNOSIS:, Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:, The Olympus gastroscope was used. The scope was placed in the upper esophagus under direct visit. The esophageal mucosa was entirely normal. There was no evidence of erosions or ulceration. There was no evidence of varices. The body and antrum of the stomach were normal. They pylorus duodenum bulb and descending duodenum are normal. There was no blood present within the stomach.,The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach. When this was done, a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold. The lesion was not bleeding. If this fold were in any other location of the stomach, I would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix. As such, the erosion may be more significant. There was no bleeding. Obviously, no manipulation of the lesion was undertaken. The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1. Solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2. Otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,PLAN:,1. Liver profile today.,2. Being Nexium 40 mg a day.,3. Scheduled colonoscopy for next week.
## 688 PREOPERATIVE DIAGNOSIS:,1. Left chronic anterior and posterior ethmoiditis.,2. Left chronic maxillary sinusitis with polyps.,3. Left inferior turbinate hypertrophy.,4. Right anterior and posterior chronic ethmoiditis.,5. Right chronic maxillary sinusitis with polyps.,6. Right chronic inferior turbinate hypertrophic.,7. Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1. Left chronic anterior and posterior ethmoiditis.,2. Left chronic maxillary sinusitis with polyps.,3. Left inferior turbinate hypertrophy.,4. Right anterior and posterior chronic ethmoiditis.,5. Right chronic maxillary sinusitis with polyps.,6. Right chronic inferior turbinate hypertrophic.,7. Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis. She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum. Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision. A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator. The bony deflection was removed using Jansen-Middleton forceps. The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest. The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side. Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps. Approximately 10 cc total was used. The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better. The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps. Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site. The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection. Bright mucosal disease and small polypoid accumulations were noted through the sinuses also. The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy. The mucosal polypoid accumulations were cleared using the Richards essential shaver. The turbinate was partially resected from mucosally but with good shape to it. It was not desirable to remove it in its entirety. Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used. The polyps were removed. The Richards essential shaver was used to allow better exposure of the uncinate process. The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also. The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection. The inferior turbinates showed mucosal disease, polypoid accumulations, and changes. These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus. A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions. The patient tolerated the procedure well and returned to the recovery room in stable condition.
## 689 PREOPERATIVE DIAGNOSIS:, Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1. Left elbow manipulation.,2. Hardware removal of left elbow.,ANESTHESIA: ,Surgery was performed under general anesthesia.,COMPLICATIONS:, There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees. We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC: ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007. The patient underwent open reduction and internal fixation of his left elbow fracture dislocation. The patient also sustained a nondisplaced right glenoid neck fracture. The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint. The patient is neurologically intact distally. Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware. Risks and benefits of the surgery were discussed. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness. All questions were answered and the parents agreed to the above plan.,PROCEDURE: ,The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient's left upper extremity was then prepped and draped in a standard surgical fashion. Using fluoroscopy, the patient's K-wire was located. An incision was made over his previous scar. A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles. The K-wires were easily palpable. A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident. The wound was then irrigated. The triceps split was now closed using #2-0 Vicryl. The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl. The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias. A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line. At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION: ,The postoperative films demonstrated no fracture, no retained hardware. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days. The patient is to follow up in 1 week's time for a wound check. The patient was given Tylenol No. 3 for pain.
## 690 PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA: ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS: ,Female infant in cephalic presentation in OP position. Normal uterus, tubes and ovaries are noted. Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes. Normal uterus, tubes and ovaries were noted.,INDICATIONS: ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery. The patient was admitted and cervix was found to be 1 cm dilated. Pitocin augmentation of labor was started. The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me. At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest. Vaginal exam was done. Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations. At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section. Clock in the operating room is noted to be 2 minutes faster then the time on trace view. The OR delivery time was 19:36. Delivery of this infant was performed in 14 minutes from the onset of the deceleration. Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s. Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt. 2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine. As the incision site was being injected, the anesthesiologist arrived. The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique. The rectus muscles were separated in midline. The peritoneum was bluntly dissected. The bladder blade was inserted. The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction. The infant was subsequently delivered. Immediately following delivery of the infant. The infant was noted to be crying with good tones. The cord was clammed and cut. The infant was subsequently transferred or handed to the nursery nurse. The placenta was delivered manually intact with a three-vessel cord noted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was repaired in 2 layers using 0 chromic sutures. Hemostasis was visualized. The uterus was returned to the abdomen. The pelvis was copiously irrigated. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was reapproximated with 0 Vicryl suture. The subcutaneous layer was closed with 2-0 plain gut. The skin was closed in the subcuticular stitch using 4-0 Monocryl. Steri-strips were applied. Sponge, laps, and instrument counts were correct. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
## 691 PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago. She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube. A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach. The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms. Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,MEDICATIONS: , Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.,INSTRUMENT: , GIF 160.,PROCEDURE REPORT:, Informed consent was obtained from Mrs. ABC's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications. Consent was not obtained from Mrs. Morales due to her recent narcotic administration. Conscious sedation was achieved with the patient lying in the left lateral decubitus position. The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,FINDINGS:,1. ESOPHAGUS: There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length. Multiple biopsies were obtained from this region and placed in jar #1.,2. STOMACH: Small hiatal hernia was noted within the cardia of the stomach. There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach. The remainder of the stomach examination was normal. There was no feeding tube remnant seen within the stomach.,3. DUODENUM: This was normal.,COMPLICATIONS:, None.,ASSESSMENT:,1. Grade C esophagitis seen within the distal, mid, and proximal esophagus.,2. Small hiatal hernia.,3. Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,PLAN: , Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.
## 692 TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:, Abdominal pain.,POSTOPERATIVE DIAGNOSIS:, Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS: ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods. She has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time. She was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing. Ultrasound was normal and a HIDA scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain. Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy.,PROCEDURE: , The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum. Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication.,IMPRESSION: ,Normal endoscopy.,PLAN: , Refer to a general surgeon for consideration of cholecystectomy.
## 693 PROCEDURE: ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze. Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions. Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus. Saccadic movements did not reveal any evidence of dysmetria or overshoot. Sinusoidal tracking was performed well for the patient's age. Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands. Therefore adequate OKNs were not achieved. The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again. The patient complained of severe dizziness in this position. There was no clear-cut decremental response with repetition. In the head hanging left position, no significant nystagmus was identified. Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <